A nurse is assessing a client who is lethargic, diaphoretic, and difficult to arouse. The client's blood sugar result was 40 mg/dL. The nurse anticipates which of the following to be administered?
Glucose tablets
Epinephrine
IVP dextrose 50%
4 oz of orange juice
The Correct Answer is C
A. Glucose tablets are appropriate for clients with mild hypoglycemia who are alert and able to chew and swallow; they are not suitable for someone who is difficult to arouse.
B. Epinephrine is not used as a treatment for hypoglycemia; it does not directly increase blood glucose levels.
C. IVP (intravenous push) dextrose 50% is indicated for severe hypoglycemia in clients who are lethargic or unresponsive, as it rapidly increases blood glucose levels.
D. Orange juice is effective for mild hypoglycemia but is not appropriate in this case due to the client’s altered mental status and risk of aspiration.
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Correct Answer is C
Explanation
A. PT/INR is not the appropriate measure for heparin therapy, as heparin is monitored using activated partial thromboplastin time (aPTT). This response could mislead the client regarding treatment expectations.
B. While it may take time to reach therapeutic levels, this statement doesn't clarify that heparin is not a clot-dissolving agent.
C. Heparin prevents the extension of existing clots and the formation of new clots but does not actively dissolve clots already present.
D. This statement incorrectly suggests that immediate effects are seen, which is not the case as heparin's action involves prevention rather than dissolution.
Correct Answer is C
Explanation
A. Asking what the usual pill looks like may not provide clarity and does not address the client's concern directly.
B. While the statement is accurate, it does not provide the client with reassurance or address the reason for the difference in appearance.
C. This response acknowledges the client's concern, offers an explanation about variations in medication appearance due to different manufacturers, and reassures the client that it is the same medication prescribed.
D. Suggesting that the pill is from a different lot number does not address the fact that variations in appearance can occur due to different manufacturers, which is more common and relevant to the situation.