when a client informs the nurse that he is experiencing hypoglycemia the nurse provides immediate intervention by providing when a client informs the nurse that he is experiencing hypoglycemia the nurse provides immediate intervention by providing
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Nursing Elites

NCLEX NCLEX-PN

NCLEX PN 2023 Quizlet

1. When a client informs the nurse that he is experiencing hypoglycemia, the nurse provides immediate intervention by providing:

Correct answer: 2–3 teaspoons of honey

Rationale: The correct immediate intervention for hypoglycemia is to provide 10–15 grams of fast-acting simple carbohydrates orally if the client is conscious and able to swallow. This can be achieved by giving 2–3 teaspoons of honey. Honey is a quick source of simple sugars that can rapidly raise blood glucose levels. Commercially prepared glucose tablets or 4–6 ounces of fruit juice are also appropriate options. However, adding sugar to fruit juice is unnecessary as the natural fruit sugar in juice already provides enough simple carbohydrates to raise blood glucose levels. Hard candies are not the best choice for immediate intervention in hypoglycemia as they may not provide a sufficient amount of fast-acting carbohydrates needed to raise blood sugar levels quickly.

2. Which of these should not be included when calculating a client’s fluid intake?

Correct answer: pudding

Rationale: Pudding is a semi-solid and does not contribute significantly to fluid intake as it does not melt at room temperature. Therefore, it should not be included in fluid intake calculations. On the other hand, ice chips, Jell-O™, and IV fluid from an antibiotic piggyback are all sources of fluid that can significantly contribute to a client's total fluid intake and should be considered when calculating it. Ice chips and Jell-O™ provide hydration upon melting, while IV fluid directly adds to the fluid volume in the body.

3. A nurse is preparing to assess a client for the presence of the Tinel sign. Which action does the nurse take to elicit this sign?

Correct answer: Percussing at the location of the median nerve

Rationale: The Tinel sign is elicited by percussing at the location of the median nerve at the wrist. In carpal tunnel syndrome, this test can produce burning and tingling along the nerve's distribution. Choices A, C, and D are incorrect. Testing for the strength of each muscle joint and checking for repetitive movements in the joints involve different assessments unrelated to the Tinel sign. Asking the client to flex the wrist 90 degrees while holding the hands back to back is associated with the Phalen test, which is another evaluation for carpal tunnel syndrome.

4. Priorities designated as intermediate by the nurse are:

Correct answer: the nonemergency, non-life-threatening needs of the client.

Rationale: Priorities designated as intermediate by the nurse are those that are not urgent but still important, such as the nonemergency, non-life-threatening needs of the client. They do not impact the client’s immediate physiological status but require attention. Intermediate priorities may need the skill level of an RN for completion and may have specific time requirements. Choices B, C, and D are incorrect because the priority being intermediate doesn't mean it can be delegated, done at a specific time, or done at any time; it simply indicates a non-urgent but necessary task for the client's well-being.

5. When a client needs oxygen therapy, what is the highest flow rate that oxygen can be delivered via nasal cannula?

Correct answer: 6 liters/minute

Rationale: The correct answer is 6 liters/minute. When a client needs oxygen therapy, the highest flow rate that oxygen can be delivered via nasal cannula is 6 liters/minute. Higher flow rates must be delivered by a mask. Choices A, B, and D are incorrect because they suggest flow rates that exceed what can be effectively delivered through a nasal cannula.

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