While we may (un-) lovingly deride the NCLEX for its structure (the most correct answer, anyone?), it does do a good job of evaluating nursing judgement and showing what/how you should be thinking while nursing.
And it doesn’t stop with the NCLEX. Every certification exam you take is built on the same structure. Yay. So, let’s practice and check our knowledge at the same time.
Which of the following is the appropriate first intervention for someone with symptoms of hypoglycemia?
A. Immediately replace fluids.
B. Assess the patient's glucose level.
C. Assess and adjust the patient's insulin level.
D. Administer three glucose tablets.
Source: Dennison ‘Pass CCRN!’ 4th Edition, online resources
Endocrine is the theme of the week! Yay for insulin. Let’s think through these answers.
Huge clue right in the question: ‘what is the first intervention.’ Well, the first step of the nursing process is to Assess. So that narrows it down to 2 options right away.
I don’t like A, anyway. Anything that hints at panic annoys me. When I get ‘panic’ results through the EMR (electronic health record), I roll my eyes. I do not panic. I am a professional. I intervene emergently, but I don’t throw my arms up and wail. Why should I “IMMEDIATELY REPLACE FLUIDS!!!!!” There is no indication for it. And dehydration is generally a symptom of hyperglycemia, not hypoglycemia. Blech.
D is also out. I may administer glucose tablets, but if I don’t know the blood glucose, I don’t know how many to give. Glucose is a medication when it is administered to change the body’s function. And I never give medications without assessing the affected system first.
So, B and C. Both assess. Both have to do with blood glucose in some way. But if I am looking specifically for the cause of hypoglycemic symptoms, I need to know what the blood glucose is. I may adjust insulin levels if they are on an IV insulin infusion. But that information is not given in the question, so I cannot assume that’s what is happening.
Thus, the correct answer is B. Assess the patient's glucose level.
Pro-nurse tip: a patient may experience relative hypoglycemia. If you check their level and the glucose is 110, they are technically not hypoglycemic. But if their A1C is 12%, their fasting glucose is close to 300mg/dl. (I’ve seen a 16% - yikes!) They are likely extremely insulin resistant and have no glucose uptake with plasma concentrations so low compared to their ‘normal.’ They probably feel like garbage. Let them eat something, especially with some protein, and keep them hydrated.
You can’t fix this chronic problem with a few jabs of insulin. Keeping them stable, even if hyperglycemic, is better than yo-yoing high and low.
How’d you do? Questions? Confusion? Too easy? Comment and let me know if you have any sore spots you want to review.
References
Porth’s Pathophysiology: Concepts of Altered Health States (9th Edition). Grossman, S.C., Porth, C.M.
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Enjoy!
Anna, RN, BSN, CCRN
Necessary disclaimer: I am discussing medications and medical conditions in this article based on my personal experiences as a nurse. Your facility may have different requirements and resources. Use your own nursing judgement to assess and treat your patients according to your governing body and facility guidelines. All information within this article is correct to the best of my knowledge, but should be confirmed through verified evidence-based sources. I am not responsible for any clinical decisions made based on this article.