a nurse is caring for a client who has diabetes mellitus and is experiencing hypoglycemia which of the following actions should the nurse take
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ATI PN Comprehensive Predictor 2023 Quizlet

1. A client with diabetes mellitus is experiencing hypoglycemia. Which of the following actions should the nurse take?

Correct answer: C

Rationale: Administering 4 oz of orange juice is the appropriate action for a client experiencing hypoglycemia due to diabetes mellitus. Orange juice contains simple sugars that can quickly raise blood glucose levels. Insulin (Choice A) would further lower blood sugar, worsening the condition. Glucagon (Choice B) is used in severe hypoglycemia when the client cannot take anything by mouth. Administering 1 L of water (Choice D) is not indicated in hypoglycemia treatment; the priority is to raise blood sugar levels. Therefore, the correct choice is to administer orange juice to address the low blood sugar in this situation.

2. When providing discharge instructions for a client with home oxygen, what safety measure should the nurse emphasize?

Correct answer: D

Rationale: The correct answer is to keep the oxygen equipment at least 6 feet away from heat sources. Placing oxygen equipment near heat sources can lead to fire hazards due to the oxygen's combustible nature. Option A is the correct safety measure as smoking near oxygen equipment can cause fires due to oxygen's flammable properties. Option B regarding the use of non-flammable bedding is not directly related to oxygen safety. Option C is important for proper oxygen tank functioning but is not as critical as keeping the equipment away from heat sources to prevent fires.

3. Which intervention is most important for a client with rheumatoid arthritis?

Correct answer: D

Rationale: The most important intervention for a client with rheumatoid arthritis is to assist with heat application and range of motion exercises. Heat application helps reduce stiffness and improve joint flexibility, while range of motion exercises help maintain mobility and prevent contractures. Massaging inflamed joints with creams and oils may provide temporary relief but does not address the root cause of stiffness and limited mobility in rheumatoid arthritis. Providing support to flexed joints with pillows and pads can be helpful for comfort but does not actively promote mobility. Positioning the client on their abdomen several times a day is not a standard intervention for managing rheumatoid arthritis.

4. A nurse is caring for a client with dementia who is at risk of falls. What is the most appropriate intervention?

Correct answer: A

Rationale: The most appropriate intervention for a client with dementia at risk of falls is to use a bed exit alarm to notify staff of attempts to leave the bed. This intervention allows for timely assistance and prevents falls. Raising all four side rails (Choice B) can lead to entrapment or agitate the client. Encouraging frequent ambulation with assistance (Choice C) may not be suitable for a client at high risk of falls. Using restraints (Choice D) should be avoided as they can increase agitation, risk of injury, and have ethical implications.

5. A client with dementia is at risk of falls. Which intervention should the nurse implement to ensure safety?

Correct answer: B

Rationale: The correct intervention for a client with dementia at risk of falls is to use a bed exit alarm to notify staff when the client tries to leave the bed. This intervention helps prevent falls while still allowing some freedom of movement. Choice A is incorrect because using restraints can lead to complications and is considered a form of restraint which should be avoided. Choice C is not suitable for a client at high risk of falls due to dementia as it may increase the risk of falls. Choice D is not recommended as raising all four side rails can be considered a form of physical restraint and may not be the best approach to prevent falls in a client with dementia.

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