The nurse has reviewed the information from the Laboratory R...

The nurse has reviewed the information from the Laboratory Results.Three days later, the school nurse is called to the play area because the client is diaphoretic and becomes unconscious. The school nurse notices the clients medical alert bracelet and obtains a blood glucose level. Which action should the school nurse take after reading the blood glucose level?

A. Administer subcutaneous glucagon
B. Administer subcutaneous regular insulin
C. Encourage the client to take sips of an electrolyte drink
D. Provide the client with a snack containing 15 g of simple carbohydrates

Correct Answer: A

Rationale: Rapid growth and unpredictable eating patterns place a child with diabetes mellitus at high risk for hypoglycemia.
Hypoglycemia can occur rapidly and can be life-threatening. Clinical manifestations primarily result from lack of glucose to the
brain (and other vital organs) followed by rapid activation of the sympathetic nervous system:
• Pallor and diaphoresis
• Tremors
• Palpitations and tachycardia
• Altered mental status, irritability, slurred speech, confusion
• Dizziness
If hypoglycemia is suspected, the nurse should immediately obtain a blood glucose level. Clients with hypoglycemia who are
unconscious cannot tolerate oral carbohydrates. Therefore, the nurse should rapidly administer glucagon by injection (eg.
subcutaneous, IM) or apply a glucose paste to the gums. Glucagon increases blood glucose levels by rapidly converting
stored glycogen in the liver into glucose, a process known as glycogenolysis

The nurse has reviewed the information from the Laboratory Results. The nurse suspects that the client may have hyperemesis gravidarum. Which of the following findings support this diagnosis? Select a that apply.

A. Hematocrit level
B. Potassium level
C. TSH level
D. Urine ketones
E. Urine specific gravity

Correct Answer: A,B,D,E

Rationale: Hyperemesis gravidarum (HG) is characterized by severe, persistent nausea and vomiting during pregnancy and weight loss of 25% of
prepregnancy weight. The exact cause of HG is unknown, but it is believed that pregnancy-related increases in hormone levels (eg, human
chorionic gonadotropin [hCG]) contribute to the condition. Laboratory findings that assist with the diagnosis of HG include:
• Elevated hematocrit level reflects hemoconcentration, which occurs due to dehydration from excessive vomiting and decreased fluid
intake (Option 1).
• Hypokalemia occurs due to excessive loss of potassium via vomiting and/or insufficient intake of potassium (Option 2).
• Ketonuria (ie, the presence of ketones in urine) results from the metabolism of fat for energy due to a lack of nutritional intake (Option
4).
• High urine specific gravity reflects the concentration of urine; concentrated urine may indicate that the client's volume is depleted,
which is common in HG (Option 5).

Select 5 findings that require immediate follow-up.

A. sore throat and nasal congestion for the past week
B. Pregnancy status is
unknown.
C. The abdomen is soft without rigidity or
rebound tenderness,
D. appears drowsy and is oriented to person and time on
E. Vital signs are T 98.8 F (37.1 C), V P 128, V RR 30, and BP 88/60 mm Hg
F. Finger-stick blood glucose level is 600 mg/dL (33.3 mmol/L) .

Correct Answer: B,D,E,F

Rationale: This client has findings of chronic hyperglycemia, including polydipsia (increased thirst) and polyuria (increased urination) which may indicate
untreated diabetes mellitus. Recent findings also indicate potential upper respiratory infection, hypovolemia, and an acute abdominal
condition. For this client, the following findings are the priority for follow-up:
• Delayed menstruation (time since last menstruation exceeds typical cycle length) could indicate that the client is pregnant, which
presents a risk for pregnancy-related complications (eg, ruptured ectopic pregnancy) and affects care provided to the client (eg, avoid x-
rays and teratogenic medications).
• Decreased level of consciousness (eg, drowsiness, disorientation) places the client at increased risk for injury and aspiration and
may indicate impaired brain perfusion. This may be due to hypotension or hyperglycemia-induced cerebral edema.
• Hypotension causes impaired organ perfusion that could be life threatening without immediate intervention.
• Tachycardia occurs to compensate for hypotension or can be the cause of hypotension and requires prompt attention to prevent
cardiovascular collapse.
• Tachypnea is concerning, particularly when associated with rapid, deep respirations (ie, Kussmaul breathing), because it may indicate a
compensatory response to an underlying metabolic acidosis (eg, ketoacidosis, hypotension-induced lactic acidosis).
• Severe hyperglycemia may indicate diabetic ketoacidosis (DKA), a life-threatening complication of diabetes mellitus. In addition,
hyperglycemia has a diuretic effect leading to fluid loss that worsens cardiovascular compromise.

The nurse is reviewing the collected client data to assist with preparing the client's plan of care. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the
nurse should take to address the condition, and 2 parameters the nurse should monitor to measure the client's progress.

A. Administer magnesium sulfate, Encourage small, frequent meals, Administer morphine, Prepare the client for birth, Administer a proton pump inhibitor
B. Pancreatitis, HELLP syndrome, Hyperemesis gravidarum, Gastroesophageal reflux disease
C. Lipase level, Urine ketones, Parameters to Monitor, Clotting factors, Postprandial pain , Deep tendon reflexes

Correct Answer:

Rationale: HELLP (Hemolysis, Elevated Liver enzymes, and Low Platelet count) syndrome is a life-threatening pregnancy-related disorder that typically
occurs >20 weeks gestation. Although HELLP syndrome is often considered a variant of preeclampsia, clients can develop this syndrome
without hypertension or proteinuria. Clinical manifestations may include elevated liver enzymes, right upper quadrant pain (due to swelling of
the liver), malaise, nausea, and decreased platelet count.
Appropriate interventions include:
• Preparing the client for birth, which is the only definitive treatment
• Assisting with the initiation of magnesium sulfate infusion for seizure prophylaxis
• Administering antihypertensive medications PRN to help prevent stroke
• Evaluating deep tendon reflexes frequently to monitor for hyperreflexia and clonus, which may indicate increased central nervous
system irritability and precede eclampsia; hyporeflexia may indicate magnesium toxicity.
• Monitoring clotting factors to evaluate bleeding risk and monitor for disseminated intravascular coagulation, a complication of HELLP
syndrome

Drag words from the choices below to fill in the blank/blanks.The nurse understands that the client is most at risk for------------and------------

A. Sepsis
B. Delirium tremens
C. Respiratory failure
D. Deep venous thrombosis
E. Decreased cardiac output

Correct Answer: E,C

Rationale: The nurse understands that the client is most at risk for respiratory failure and decreased cardiac output.
Decreased cardiac output is the most concerning complication in a client with a tension pneumothorax. The trapped air in a tension
pneumothorax causes increased pressure, compressing the affected lung more until it is completely collapsed and then compressing the
heart and great vessels (vena cava, aorta), ultimately inhibiting venous return.
If the pleural pressure continues to increase, eventually the pleural cavity will crowd the trachea, forcing it to deviate (shift) to the unaffected
side where the unaffected lung can be compressed. Clients are at high risk for respiratory failure due to hypoxemia. Without treatment, the
lungs cannot meet the demands for oxygenation and the client will die.

Drag words from the choices below to fill in the blanks. The nurse should prioritize interventions for acute decompensated heart failure to reduce the risk of the client developing-----------------------and ------------------

A. Acute kidney injury
B. Bacterial endocarditis
C. Disseminated intravascular coagulation
D. Acute Kidney Injury
E. Dysrhythmias

Correct Answer: D,E

Rationale: Dyshythmias due to structural changes (eg, cardiomegaly, ventricular hypertrophy) that alter electrical activity of the
heart. Common dysrhythmias associated with HF include atrial fibrillation, life-threatening ventricular tachycardia, and
ventricular fibrillation.
• Acute kidney injury (AKI) due to hypoperfusion of vital organs (ie, decreased renal perfusion) secondary to decreased
cardiac output. Decreased glomerular filtration can cause electrolyte imbalances (eg, hyperkalemia) related to AKI that
can also be a precipitating factor for dyshythmias.
• Pleural effusions can develop when fluid moves from capillaries to free spaces in the thoracic cavity as hydrostatic
pressure in the pulmonary veins increases (back pressure).