Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has gestational diabetes and reports feeling shaky, sweaty, and having blurred vision. The client's blood glucose level is 48 mg/dL. Which of the following foods should the nurse give to the client? (Select all that apply).
A. 1 tbsp honey
1 tbsp honey: Honey is a quick source of glucose and is an appropriate choice to raise blood sugar rapidly during hypoglycemia.
B. 5 hard candies
5 hard candies: Hard candies containing sugar can provide a quick source of glucose and are suitable for treating hypoglycemia.
C. 240 mL regular soda
240 mL regular soda might provide 20 to 30 grams of carbohydrates, which could be too much and may lead to a rebound hypoglycemia after the initial correction of blood glucose levels.
D. 120 mL unsweetened fruit juice
Unsweetened fruit juice provides a quick source of glucose, which is essential for rapidly raising blood sugar levels in a hypoglycemic patient. The sugar in the juice is readily absorbed into the bloodstream, helping to counteract the effects of low blood sugar. It's important to choose unsweetened juice to avoid a sudden spike in blood sugar followed by another drop.
E. 120 mL milk
120 mL milk: Milk contains natural sugars and can contribute to raising blood glucose levels. However, it may not be as rapid as some other options.
This question is an excerpt from Nurse Dive's nursing test bank - ATI LPN Proctored Exam. Take the full exam now
Full Explanation
A. 1 tbsp honey: Honey is a quick source of glucose and is an appropriate choice to raise blood sugar rapidly during hypoglycemia.
B. 5 hard candies: Hard candies containing sugar can provide a quick source of glucose and are suitable for treating hypoglycemia.
C. 240 mL regular soda might provide 20 to 30 grams of carbohydrates, which could be too much and may lead to a rebound hypoglycemia after the initial correction of blood glucose levels.
D. 120 mL unsweetened fruit juice: Unsweetened fruit juice provides a quick source of glucose, which is essential for rapidly raising blood sugar levels in a hypoglycemic patient. The sugar in the juice is readily absorbed into the bloodstream, helping to counteract the effects of low blood sugar. It's important to choose unsweetened juice to avoid a sudden spike in blood sugar followed by another drop.
E. 120 mL milk: Milk contains lactose, a natural sugar, but it also contains protein and fat, which can slow down the absorption of sugar into the bloodstream. Therefore, it may not be as effective in rapidly raising blood sugar levels during an episode of hypoglycemia.
Similar Questions
A nurse is reinforcing discharge teaching with the parent of a child who has a new diagnosis of diabetes mellitus. Which of the following statements by the parent requires a clarification of the teaching?
A. "Sweating can occur with hypoglycemia."
"Sweating can occur with hypoglycemia." Sweating is one of the common symptoms of hypoglycemia. When blood glucose levels drop too low, the body releases stress hormones, including adrenaline, which can lead to sweating.
B. "My son might complain of feeling shaky when he has a low blood glucose level."
"My son might complain of feeling shaky when he has a low blood glucose level." Shaking or feeling shaky is a common symptom of hypoglycemia. It results from the release of stress hormones in response to low blood glucose.
C. "My son might have nausea and vomiting with hypoglycemia."
"My son might have nausea and vomiting with hypoglycemia."Nausea and vomiting are more commonly associated with hyperglycemia, especially in diabetic ketoacidosis (DKA). They are not typical signs of hypoglycemia.
D. "The onset of low blood glucose usually occurs rapidly."
"The onset of low blood glucose usually occurs rapidly."Hypoglycemia often has a rapid onset, especially with missed meals or increased activity.
Full Explanation
A. "Sweating can occur with hypoglycemia."
Explanation: This statement is correct. Sweating is one of the common symptoms of hypoglycemia. When blood glucose levels drop too low, the body releases stress hormones, including adrenaline, which can lead to sweating.
B. "My son might complain of feeling shaky when he has a low blood glucose level."
Explanation: This statement is correct. Shaking or feeling shaky is a common symptom of hypoglycemia. It results from the release of stress hormones in response to low blood glucose.
C. "My son might have nausea and vomiting with hypoglycemia."Nausea and vomiting are more commonly associated with hyperglycemia, especially in diabetic ketoacidosis (DKA). They are not typical signs of hypoglycemia.
D. "The onset of low blood glucose usually occurs rapidly."Hypoglycemia often has a rapid onset, especially with missed meals or increased activity.
A nurse is contributing to the plan of care for a client prescribed continuous enteral feedings. Which of the following actions should the nurse plan to take?
A. Check the gastric residual every 8 hr.
Check the gastric residual every 8 hr:Explanation: It is generally recommended to check gastric residuals more frequently than every 8 hours, often every 4-6 hours, especially in the initial stages of continuous enteral feedings, to monitor tolerance and prevent complications such as aspiration.
B. Change the feeding bag every 24 hr.
Change the feeding bag every 24 hr:Explanation: Changing the feeding bag and tubing at regular intervals helps prevent bacterial contamination and maintain aseptic technique. The frequency of bag changes is typically scheduled every 24 hours or according to facility protocols.
C. Flush the tube with sterile sodium chloride solution every 2 hr.
Flush the tube with sterile sodium chloride solution every 2 hr:Explanation: While it is important to flush the feeding tube regularly to maintain patency, using sterile water is typically recommended unless there is a specific clinical indication for sterile sodium chloride. The frequency of flushing (usually every 4-6 hours for continuous feeding) should be determined based on the institution's protocol and the client's specific needs.
D. Position the head of the client's bed at 15.
Position the head of the client's bed at 15 degrees:Explanation: To reduce the risk of aspiration, the head of the bed should be elevated to at least 30-45 degrees during enteral feedings, not just 15 degrees. Elevating the head of the bed helps prevent reflux and aspiration. .
Full Explanation
Correct answer: B
A. Check the gastric residual every 8 hr:
Explanation: It is generally recommended to check gastric residuals more frequently than every 8 hours, often every 4-6 hours, especially in the initial stages of continuous enteral feedings, to monitor tolerance and prevent complications such as aspiration.
B. Change the feeding bag every 24 hr:
Explanation: Changing the feeding bag and tubing at regular intervals helps prevent bacterial contamination and maintain aseptic technique. The frequency of bag changes is typically scheduled every 24 hours or according to facility protocols.
C. Flush the tube with sterile sodium chloride solution every 2 hr:
Explanation: While it is important to flush the feeding tube regularly to maintain patency, using sterile water is typically recommended unless there is a specific clinical indication for sterile sodium chloride. The frequency of flushing (usually every 4-6 hours for continuous feeding) should be determined based on the institution's protocol and the client's specific needs.
D. Position the head of the client's bed at 15 degrees:
Explanation: To reduce the risk of aspiration, the head of the bed should be elevated to at least 30-45 degrees during enteral feedings, not just 15 degrees. Elevating the head of the bed helps prevent reflux and aspiration.
A nurse is teaching the parents of a child who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following manifestations should the nurse include in the teaching?
A. Dry mucous membranes
Dry mucous membranes:Explanation: Dry mucous membranes are not typically associated with hypoglycemia. Instead, they might be seen in conditions such as dehydration.
B. Fruity breath odor
Fruity breath odor:Explanation: Fruity breath odor is more commonly associated with diabetic ketoacidosis (DKA), which is a complication of hyperglycemia, not hypoglycemia.
C. Diaphoresis
Diaphoresis: Explanation: Diaphoresis, or excessive sweating, is a common manifestation of hypoglycemia. It results from the activation of the sympathetic nervous system in response to low blood sugar levels.
D. Polyuria
Polyuria:Explanation: Polyuria, or increased urination, is not a typical manifestation of hypoglycemia. It is more commonly associated with hyperglycemia and diabetes.
Full Explanation
A. Dry mucous membranes:
Explanation: Dry mucous membranes are not typically associated with hypoglycemia. Instead, they might be seen in conditions such as dehydration.
B. Fruity breath odor:
Explanation: Fruity breath odor is more commonly associated with diabetic ketoacidosis (DKA), which is a complication of hyperglycemia, not hypoglycemia.
C. Diaphoresis:
Explanation: Diaphoresis, or excessive sweating, is a common manifestation of hypoglycemia. It results from the activation of the sympathetic nervous system in response to low blood sugar levels.
D. Polyuria:
Explanation: Polyuria, or increased urination, is not a typical manifestation of hypoglycemia. It is more commonly associated with hyperglycemia and diabetes.
