At 4:45 p.m., a nurse assesses a client with diabetes mellitus who is recovering from an abdominal hysterectomy 2 days ago. The nurse notes that the client is confused and diaphoretic. The nurse reviews the assessment data provided in the chart below:
Capillary Blood Glucose Testing (AC/HS)
Dietary
Intake
At 0630: 95
At 1130: 70
At 1630: 47
Breakfast: 10% eaten - client states she is not hungry
Lunch: 5% eaten - client is nauseous; vomits once
After reviewing the client's assessment data, which action is appropriate at this time?
a.
Assess the client's oxygen saturation level and administer oxygen.
b.
Reorient the client and apply a cool washcloth to the client's forehead.
c.
Administer dextrose 50% intravenously and reassess the client.
d.
Provide a glass of orange juice and encourage the client to eat dinner.
ANS: C
The client's symptoms are related to hypoglycemia. Since the client has not been tolerating food, the nurse should administer dextrose intravenously. The client's oxygen level could be checked, but based on the information provided, this is not the priority. The client will not be reoriented until the glucose level rises.
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