A client with type 1 diabetes mellitus is admitted to the emergency department with confusion, sweating, and a blood sugar level of 45 mg/dL. What is the nurse's priority action?- Nurselytic

Question 1 of 5

A client with type 1 diabetes mellitus is admitted to the emergency department with confusion, sweating, and a blood sugar level of 45 mg/dL. What is the nurse's priority action?

A. Administer 50% dextrose IV push B. Provide a carbohydrate snack C. Check the client's urine for ketones D. Start an insulin drip

Correct Answer: A

Rationale: A blood sugar level of 45 mg/dL indicates severe hypoglycemia, which can lead to life-threatening complications if not treated immediately. The priority is to administer IV dextrose to rapidly increase the blood sugar level. Offering a carbohydrate snack may follow once the client is stable.

Question 2 of 5

A client with type 1 diabetes mellitus is admitted to the emergency department with confusion, sweating, and a blood sugar level of 45 mg/dL. What is the nurse's priority action?

A. Administer 50% dextrose IV push B. Provide a carbohydrate snack C. Check the client's urine for ketones D. Start an insulin drip

Correct Answer: A

Rationale: A blood sugar level of 45 mg/dL indicates severe hypoglycemia, which can lead to life-threatening complications if not treated immediately. The priority is to administer IV dextrose to rapidly increase the blood sugar level. Offering a carbohydrate snack may follow once the client is stable.

Question 3 of 5

The nurse is caring for a client with a chest tube following surgery. The nurse should intervene if which of the following is observed?

A. The chest tube is securely taped at the insertion site. B. The water seal chamber is filled to the correct level. C. The chest drainage system is below chest level. D. There are no air leaks in the system.

Correct Answer: C

Rationale: The chest drainage system should always be kept below chest level to ensure proper drainage.

Question 4 of 5

The nurse observes that a client's wrist restraint is secured to the side rail of the bed. What action should the nurse take?

A. Ensure that the restraint is snug against the client's wrist. B. Reposition the restraint tie onto the bedframe. C. Double knot the restraint to ensure safety. D. Leave the restraint in place and notify the healthcare provider.

Correct Answer: B

Rationale: Restraints should always be secured to the bedframe, not the side rails, to prevent injury to the client in case the bed is adjusted.

Question 5 of 5

A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse?

A. Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception. B. This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen and no sperm are in your ejaculate. C. After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in seven to ten days. D. The health care provider at this clinic recommends rest, ice, an athletic supporter or over-the-counter pain medication to relieve any discomfort.

Correct Answer: A

Rationale: It is important to use contraception until sperm is confirmed absent in the ejaculate.

Nurselytic

HESI RN

HESI RN

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