During the 0700 Beginning of the Shift Assessment, the Nurse

question 13

Multiple Choice

During the 0700 beginning of the shift assessment, the nurse finds a client who was diagnosed with type I diabetes mellitus to be difficult to arouse. Per unit protocol, arterial blood gases and a blood glucose are performed. The results show pH 7.01, PO₂ 92, PCO₂ 36, HCO₃ 9, blood glucose 873. What action should the nurse take first?

• A)Administer the client's 0800 dose of NPH insulin immediately.
• B)Notify the physician and the house supervisor of the client's condition.
• C)Begin an IV line with 0.5% normal saline and prepare sodium bicarbonate for administration.
• D)Attempt to arouse the client and determine what he ate the previous evening to raise his blood glucose.

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Definitions:

Veins

Tubes forming part of the blood circulation system of the body, carrying in most cases oxygen-depleted blood towards the heart.

Axillary Artery

An artery that carries oxygenated blood to the axilla (armpit) area and to the upper limb.

Brachium

The upper arm area between the shoulder and the elbow.

Costocervical Artery

An artery that supplies blood to the upper dorsal region of the body, including parts of the neck and shoulders.