A client is acutely confused, sweating, and complaining of a headache. The nurse suspects hypoglycemia. The nurse's next action is to obtain:
1. a serum blood glucose.
2. a glucose tolerance test.
3. serum electrolytes.
4. a capillary blood glucose level.
Correct Answer: 4
Rationale 1: A serum blood glucose test would not provide the immediate information needed to correct the hypoglycemia.
Rationale 2: A glucose tolerance test measures glucose levels after 2 hours; it would not provide the immediate information needed to correct the hypoglycemia.
Rationale 3: Serum electrolytes will not provide the level of blood sugar needed to intervene with hypoglycemia.
Rationale 4: Obtaining a finger-stick blood sugar takes 15 seconds and provides an opportunity for rapid nursing intervention, if needed.
Global Rationale: Obtaining a finger-stick blood sugar takes 15 seconds and provides an opportunity for rapid nursing intervention, if needed. A serum blood glucose test would not provide the immediate information needed to correct the hypoglycemia. A glucose tolerance test measures glucose levels after 2 hours; it would not provide the immediate information needed to correct the hypoglycemia. Serum electrolytes will not provide the level of blood sugar needed to intervene with hypoglycemia.
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