A client diagnosed with type 1 diabetes suddenly reports feeling weak, shaky, and dizzy. What should be the nurse's initial response?
Perform a blood sugar analysis.
Have the client drink a 4-ounce (120-mL) glass of orange juice.
Administer 1 ampule of 50% dextrose intravenously.
Administer 10 units of regular insulin subcutaneously.
The Correct Answer is B
A. Performing a blood sugar analysis is important, but in the case of sudden symptoms such as weakness, shakiness, and dizziness, it is crucial to act quickly to address the potential hypoglycemia without delay.
B. Having the client drink a 4-ounce glass of orange juice is the most appropriate initial response as it provides a quick source of glucose to alleviate symptoms of hypoglycemia, which is a common concern in clients with type 1 diabetes experiencing these symptoms.
C. Administering 1 ampule of 50% dextrose intravenously is an effective treatment for hypoglycemia but is typically reserved for severe cases where the patient is unable to consume oral glucose or is unconscious.
D. Administering 10 units of regular insulin subcutaneously would exacerbate the problem by lowering blood sugar further and is contraindicated in a patient experiencing hypoglycemic symptoms.
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Correct Answer is D
Explanation
A. Nitrates do not share a cross-sensitivity with penicillin and are safe to use in this client.
B. Tetracycline is a different class of antibiotics and does not have cross-sensitivity with penicillin.
C. Aminoglycosides also do not have cross-sensitivity with penicillin and can be safely administered.
D. Cephalosporins are structurally related to penicillin and have a risk of cross-sensitivity; thus, they should not be given to a client with a history of anaphylaxis to penicillin.
Correct Answer is B
Explanation
A. Administer the insulin to the client is incorrect as the nurse should first verify the dosage for safety before administration.
B. Check the dosage with another nurse is correct because double-checking the insulin dosage with another licensed nurse is a critical safety step to prevent medication errors.
C. Check the client's blood sugar again is incorrect; while monitoring blood sugar is important, it is not the immediate next action after preparing the insulin.
D. Ensure a meal tray is available is incorrect; although the client should have a meal ready after insulin administration, the priority action before administering the medication is to confirm the dosage.