NCLEX-RN (Registered Nurse) Practice Exam · Question
A 55-year-old client with type 2 diabetes receiving continuous subcutaneous insulin infusion reports feeling shaky, dizzy, and sweaty. A bedside glucose reading is 2.8 mmol/L. The nurse has identified hypoglycemia as the primary concern. Which intervention represents the 'Generate Solutions' step of the Clinical Judgment Measurement Model?
Generating solutions involves developing a range of possible interventions to address the client's needs. Before implementing, the nurse considers various optio
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Question: A 55-year-old client with type 2 diabetes receiving continuous subcutaneous insulin infusion reports feeling shaky, dizzy, and sweaty. A bedside glucose reading is 2.8 mmol/L. The nurse has identified hypoglycemia as the primary concern. Which intervention represents the 'Generate Solutions' step of the Clinical Judgment Measurement Model?
Answer options:
- Administering D50W intravenously as per standing orders.
- Re-checking the blood glucose level in 15 minutes to confirm effectiveness. ✅ Asking the client what they prefer to eat or drink to raise their blood glucose.
- Notifying the physician about the client's hypoglycemic episode.
Correct answer: Asking the client what they prefer to eat or drink to raise their blood glucose.
Explanation: Generating solutions involves developing a range of possible interventions to address the client's needs. Before implementing, the nurse considers various options. In this situation, offering the client an oral carbohydrate is a primary intervention for mild to moderate hypoglycemia in a conscious client.
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