A client is in shock and the nurse prepares to administer insulin ...

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A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best?
 
  a. High glucose is common in shock and needs to be treated.
  b. Some of the medications we are giving are to raise blood sugar.
  c. The IV solution has lots of glucose, which raises blood sugar.
  d. The stress of this illness has made your spouse a diabetic.

Question 2

A nurse is caring for a client after surgery who is restless and apprehensive. The unlicensed assistive personnel (UAP) reports the vital signs and the nurse sees they are only slightly different from previous readings.
 
  What action does the nurse delegate next to the UAP?
  a.
  Assess the client for pain or discomfort.
  b.
  Measure urine output from the catheter.
  c.
  Reposition the client to the unaffected side.
  d.
  Stay with the client and reassure him or her.

[FergA]

Answer to Question 1

ANS: A
High glucose readings are common in shock, and best outcomes are the result of treating them and maintaining glucose readings in the normal range. Medications and IV solutions may raise blood glucose levels, but this is not the most accurate answer. The stress of the illness has not made the client diabetic.

Answer to Question 2

ANS: B
Urine output changes are a sensitive early indicator of shock. The nurse should delegate emptying the urinary catheter and measuring output to the UAP as a baseline for hourly urine output measurements. The UAP cannot assess for pain. Repositioning may or may not be effective for decreasing restlessness, but does not take priority over physical assessments. Reassurance is a therapeutic nursing action, but the nurse needs to do more in this situation.

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TYSM

[pangili4]

Excellent