Nursing Exam Prep

NCLEX-RN: More topics practice questions questions 126-150

192 questions, page 6 of 8. Try each one first, then open the answer.

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126Question

A client has taken haloperidol for three years. During a routine abnormal movement screening the nurse sees rhythmic tongue protrusion, lip smacking and chewing movements. What should the nurse do?

  1. Reassure the client that dry mouth commonly causes these movements
  2. Document the finding and report it to the prescriber promptly
  3. Advise the client to stop the haloperidol immediately
  4. Give the as-needed benztropine to relieve the movements
Show the answer and explanation

Answer: B. Document the finding and report it to the prescriber promptly

Topic: tardive dyskinesia

These are signs of tardive dyskinesia, a late and sometimes irreversible effect of dopamine-blocking antipsychotics. The prescriber reviews the drug and options; the nurse documents and reports without stopping the drug abruptly.

Why the others are wrong

  • A – Dismissing a serious sign delays a drug review while the condition may still be reversible.
  • C – Stopping a drug unilaterally is outside nursing scope and risks relapse.
  • D – Benztropine treats acute extrapyramidal symptoms, not tardive dyskinesia, and may worsen it.

Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.

127Question

The nurse has taught progressive muscle relaxation to a client who becomes very tense before dressing changes. Which statement by the client shows correct use of the technique?

  1. 'I tighten every muscle in my body at once and hold my breath for as long as I can.'
  2. 'I save it for when the tension is at its very worst, because using it earlier would waste it.'
  3. 'If it has not worked the first time I try it, the technique is not right for me.'
  4. 'I tense one muscle group for a few seconds, then let it go and notice the difference, working up from my feet while breathing slowly.'
Show the answer and explanation

Answer: D. 'I tense one muscle group for a few seconds, then let it go and notice the difference, working up from my feet while breathing slowly.'

Topic: progressive muscle relaxation

Progressive muscle relaxation involves tensing and then releasing one muscle group at a time in sequence, with slow breathing and attention to the contrast between tension and release. It is a skill that improves with regular practice and works best when begun early, before tension peaks.

Why the others are wrong

  • A – Tensing everything together while holding the breath raises tension and pressure instead of producing relaxation.
  • B – Relaxation techniques work best when started early and practiced regularly, not kept for the peak of distress.
  • C – The technique is a learned skill; benefit builds with repeated practice.

Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.

128Question

A military veteran with posttraumatic stress disorder is on a surgical unit. When a metal tray crashes to the floor in the hallway, the nurse finds the client crouched beside the bed, sweating, staring and shouting, 'Get down! Get down!' Which action should the nurse take first?

  1. Take hold of the client's arm and help the client back into bed.
  2. Stay a few steps away and say in a calm, clear voice who you are, where the client is, and that the client is safe.
  3. Ask the client to describe what happened during the combat event being remembered.
  4. Leave the room, close the door and return when the episode has passed.
Show the answer and explanation

Answer: B. Stay a few steps away and say in a calm, clear voice who you are, where the client is, and that the client is safe.

Topic: posttraumatic stress response to a trigger

A sudden loud noise has triggered a dissociative flashback, in which the client re-experiences the trauma as if it were happening now. The nurse's first aim is safety and grounding in the present: keeping distance, avoiding touch, and using a calm voice to orient the client to person, place and safety. Exploring the trauma belongs to planned therapy, not to the acute episode.

Why the others are wrong

  • A – Unexpected touch during a flashback can be experienced as an assault and may provoke a defensive reaction.
  • C – Asking for the details of the trauma deepens the re-experiencing instead of bringing the client back to the present.
  • D – Leaving a client who is not oriented to the present is unsafe and loses the chance to ground the client.

Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.

129Question

A veteran with posttraumatic stress disorder crouches behind a chair when a cart clatters in the hall, stares wide-eyed, and whispers, "They're coming." What should the nurse do first?

  1. Grasp the client's shoulders firmly to bring the client back
  2. Ask the client to describe the memory in detail
  3. Speak calmly from a distance using the client's name, say where the client is and that it is safe now
  4. Leave the client alone until the behavior stops
Show the answer and explanation

Answer: C. Speak calmly from a distance using the client's name, say where the client is and that it is safe now

Topic: flashback response

During a flashback the client is reliving the trauma. A calm voice, use of the name, and orientation to the present help grounding, while sudden touch may be seen as an attack.

Why the others are wrong

  • A – Unexpected touch may be perceived as an attack and cause violence.
  • B – Detailed recall during a flashback intensifies reliving.
  • D – Leaving a frightened client alone increases fear and risk.

Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.

130Question

Twelve days after a serious car crash, a client reports intrusive memories, avoids driving, is startled easily, sleeps poorly and sometimes feels detached from surroundings. Which condition fits this timeline?

  1. Posttraumatic stress disorder
  2. Acute stress disorder
  3. Adjustment disorder
  4. Generalized anxiety disorder
Show the answer and explanation

Answer: B. Acute stress disorder

Topic: acute stress disorder

Acute stress disorder appears from three days up to one month after exposure to a traumatic event. When the same symptoms last longer than one month, posttraumatic stress disorder is diagnosed.

Why the others are wrong

  • A – PTSD requires symptoms for more than one month.
  • C – Adjustment disorder follows a lesser stressor and lacks this trauma symptom picture.
  • D – GAD is persistent worry for months without a traumatic exposure.

Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.

131Question

The nurse is planning care for a client with a severe traumatic brain injury and rising intracranial pressure. Which interventions are appropriate?

Select all that apply.

  1. Elevate the head of the bed about 30 degrees with the head in midline
  2. Keep the neck neutral and avoid tight cervical ties that compress the jugular veins
  3. Cluster all care and procedures into one continuous block of time
  4. Suction frequently as a preventive routine
  5. Prevent and treat fever
  6. Encourage forceful coughing to clear secretions
Show the answers and explanation

Answers: A, B and E.

  • A – Elevate the head of the bed about 30 degrees with the head in midline
  • B – Keep the neck neutral and avoid tight cervical ties that compress the jugular veins
  • E – Prevent and treat fever

Topic: ICP care

Head elevation with a neutral neck promotes venous drainage. Fever raises metabolic demand and intracranial pressure, so it is treated. Stimulation, suctioning without need and straining raise pressure.

Why the others are wrong

  • C – Long continuous blocks of care allow no recovery time and cause cumulative ICP rises; space activities.
  • D – Suction only when needed and briefly; each pass can raise ICP.
  • F – Coughing and straining (Valsalva) raise intracranial pressure.

Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.

132Question

Which set of vital signs in a client with a head injury is the most concerning for impending brain herniation?

  1. Blood pressure 100/70 mm Hg, heart rate 112/min, respirations 24/min and regular
  2. Blood pressure 118/76 mm Hg, heart rate 80/min, respirations 18/min
  3. Blood pressure 92/60 mm Hg, heart rate 120/min, respirations 30/min
  4. Blood pressure 190/80 mm Hg, heart rate 50/min, respirations slow and irregular
Show the answer and explanation

Answer: D. Blood pressure 190/80 mm Hg, heart rate 50/min, respirations slow and irregular

Topic: Cushing triad

The Cushing triad is hypertension with a widening pulse pressure, bradycardia and irregular respirations. It is a late sign that the brainstem is being compressed.

Why the others are wrong

  • A – Tachycardia with falling pressure points to shock rather than herniation.
  • B – These are normal values.
  • C – Hypotension and tachycardia suggest hemorrhagic shock, the opposite of Cushing's triad.

Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.

133Question

A 72-year-old client who fell from a ladder is brought to urgent care. The client says, "I'm fine, just sleepy," and a small scalp laceration is no longer bleeding. The client's speech is slow and slurred. Which assessment should the nurse perform first?

  1. Primary survey: airway, breathing, circulation, level of consciousness
  2. Systematic head-to-toe examination beginning at the scalp and ending at the feet
  3. Focused assessment of the scalp laceration with measurement and a description of the wound
  4. Thorough health history including medications, allergies and past surgeries
Show the answer and explanation

Answer: A. Primary survey: airway, breathing, circulation, level of consciousness

Topic: primary survey after head injury

A head injury with new drowsiness and slurred speech may indicate bleeding in or around the brain. The primary survey checks life-threatening problems in priority order and can detect deterioration; the focused and detailed assessments follow once the client is stable.

Why the others are wrong

  • B – A full head-to-toe examination comes after life-threatening problems are excluded.
  • C – The wound is minor and not bleeding; looking at it first misses the more serious threat.
  • D – A detailed history can wait until the client's airway, breathing, circulation and neurologic status are safe.

Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.

134Question

A 16-year-old comes to a school clinic with an ankle sprain from soccer two days ago and asks whether they can play on Saturday. Which type of assessment is most appropriate?

  1. Focused assessment of the ankle
  2. Head-to-toe examination with a full set of laboratory tests
  3. Primary survey for life-threatening problems followed by a full-body review
  4. Complete health assessment of all body systems and a full history
Show the answer and explanation

Answer: A. Focused assessment of the ankle

Topic: focused assessment

A focused assessment looks closely at the problem the client presents: here, pain, swelling, bruising, range of motion, circulation and sensation of the ankle and foot. The client is stable and the concern is specific, so a broad examination is unnecessary.

Why the others are wrong

  • B – A head-to-toe examination with laboratory tests is far more than this complaint requires.
  • C – A primary survey is for unstable or injured clients with life-threatening concerns.
  • D – A complete assessment is for baseline or new-client visits, not a single stable complaint.

Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.

135Question

A client admitted with suspected appendicitis rated right lower abdominal pain 9 out of 10. Thirty minutes later the client says the pain is 'much better,' but the nurse finds a rigid abdomen, a temperature of 102.2 °F (39 °C) and a rising heart rate. What should the nurse do first?

  1. Offer clear liquids because the pain has eased
  2. Notify the provider immediately about possible perforation
  3. Document the improvement in pain and recheck in four hours
  4. Apply a heating pad to the abdomen for comfort
Show the answer and explanation

Answer: B. Notify the provider immediately about possible perforation

Topic: appendicitis perforation signs

Abrupt relief of appendiceal pain can mean the appendix has ruptured and the pressure is released, but rigid abdomen, fever and tachycardia indicate peritonitis. This is an emergency that needs immediate reporting.

Why the others are wrong

  • A – The client should stay NPO because surgery is likely.
  • C – Sudden relief with new rigidity and fever is a warning sign, not an improvement.
  • D – Heat can increase blood flow to an inflamed appendix and raise the risk of rupture.

Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.

136Question

A nurse suspects urinary retention in a client who has not voided for nine hours and has lower abdominal fullness. When percussing above the symphysis pubis, which sound supports a full bladder?

  1. Tympany
  2. Resonance
  3. Dullness
  4. Hyperresonance
Show the answer and explanation

Answer: C. Dullness

Topic: percussion sounds

Percussion over fluid-filled or solid structures produces a dull sound. A bladder full of urine lies just above the pubic bone and sounds dull, while gas-filled bowel is tympanic.

Why the others are wrong

  • A – Tympany is the sound of air-filled bowel or stomach, not fluid.
  • B – Resonance is the note of normal lung tissue.
  • D – Hyperresonance is a booming sound heard over trapped air such as in emphysema or pneumothorax.

Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.

137Question

A client has blunt abdominal trauma from a steering wheel. The abdomen is rigid and tender with guarding, and blood pressure is falling. Which actions are appropriate while awaiting the surgeon?

Select all that apply.

  1. Keep the client NPO
  2. Establish two large-bore intravenous lines
  3. Apply a heating pad to the abdomen for comfort
  4. Offer sips of water to relieve thirst
  5. Prepare for type and crossmatch and possible emergency surgery
  6. Administer a laxative to relieve distension
Show the answers and explanation

Answers: A, B and E.

  • A – Keep the client NPO
  • B – Establish two large-bore intravenous lines
  • E – Prepare for type and crossmatch and possible emergency surgery

Topic: surgical abdomen

A rigid abdomen with hypotension suggests intra-abdominal bleeding or perforation. The client is kept NPO, given reliable access for fluids and blood, and prepared for surgery.

Why the others are wrong

  • C – Heat can increase bleeding and mask worsening signs.
  • D – Oral intake risks aspiration at anesthesia and is withheld.
  • F – A laxative can aggravate a perforated or injured bowel.

Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.

138Question

A client with an asthma exacerbation has been using accessory muscles and has had a rapid respiratory rate. Which new finding suggests the nurse should anticipate intubation?

  1. Loud expiratory wheezes
  2. A productive cough
  3. New drowsiness with shallow breathing and a rising PaCO2
  4. SpO2 of 93% on supplemental oxygen
Show the answer and explanation

Answer: C. New drowsiness with shallow breathing and a rising PaCO2

Topic: impending respiratory failure

Drowsiness, shallow or slowing breathing and a rising PaCO2 indicate respiratory muscle fatigue and impending failure. Wheezes and a cough show some air movement, and SpO2 of 93% on oxygen is acceptable.

Why the others are wrong

  • A – Loud wheezing shows air is still moving.
  • B – A productive cough clears secretions.
  • D – SpO2 93% on oxygen is acceptable.

Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.

139Question

A nurse will interview a 16-year-old alone for part of a well-adolescent visit after the parent steps out. Which statement should the nurse make at the start of the private interview?

  1. "What we talk about stays private, except if I worry about serious harm to you or someone else."
  2. "Whatever you tell me today will stay completely secret, no matter what you decide to tell me."
  3. "Everything you tell me will be shared with your parent so that nobody has any surprises later."
  4. "Because you are still a minor, I will keep my questions general and leave private topics to your parent."
Show the answer and explanation

Answer: A. "What we talk about stays private, except if I worry about serious harm to you or someone else."

Topic: confidentiality with adolescents

Adolescents are more honest when they trust that the conversation is confidential, but confidentiality has limits. The nurse explains up front that safety concerns such as risk of serious harm to the adolescent or others must be reported.

Why the others are wrong

  • B – An unconditional promise cannot be kept if there is a risk of serious harm.
  • C – Sharing everything with the parent removes the privacy that encourages honest answers.
  • D – Avoiding sensitive topics leaves risks such as substance use or abuse unscreened.

Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.

140Question

The daughter of a resident with advanced, declining dementia asks about hospice. Which statement by the nurse is most accurate?

  1. Hospice means all care stops
  2. Hospice is for a person whose prognosis is about six months or less if the illness runs its usual course, focuses on comfort and family support, and can be provided in the nursing home
  3. A resident must be in the last week of life to qualify
  4. Once started, hospice can never be stopped
Show the answer and explanation

Answer: B. Hospice is for a person whose prognosis is about six months or less if the illness runs its usual course, focuses on comfort and family support, and can be provided in the nursing home

Topic: Hospice eligibility concept

Hospice is comfort-focused care for people with a terminal illness and a prognosis of roughly six months or less if the disease follows its expected course, with support for the family. It can be delivered in a nursing home, and a person can end enrollment.

Why the others are wrong

  • A – Hospice adds comfort care and support; it does not mean care stops.
  • C – Eligibility is based on an estimated prognosis of months, not days.
  • D – Enrollment can be revoked.

Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.

141Question

A resident with fragile skin has a skin tear on the forearm with a viable flap. Which actions are appropriate?

Select all that apply.

  1. Control bleeding with light pressure and elevation
  2. Close the edges with adhesive tape strips
  3. Cleanse gently with saline
  4. Gently ease the flap back over the wound bed
  5. Cover with a non-adherent silicone dressing and mark the direction of removal
  6. Scrub the area with hydrogen peroxide
Show the answers and explanation

Answers: A, C, D and E.

  • A – Control bleeding with light pressure and elevation
  • C – Cleanse gently with saline
  • D – Gently ease the flap back over the wound bed
  • E – Cover with a non-adherent silicone dressing and mark the direction of removal

Topic: Skin tear management

Skin tear care is gentle: stop bleeding, cleanse with saline, realign a viable flap without stretching, and use a non-adherent dressing marked with an arrow showing the direction of removal so the flap is not lifted. Adhesive strips and harsh cleansers cause further trauma.

Why the others are wrong

  • B – Adhesive strips can tear fragile skin when removed.
  • F – Hydrogen peroxide damages tissue and delays healing.

Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.

142Question

A client with a large burn is receiving intravenous crystalloid by a resuscitation formula. Six hours after the burn the urine output has been below the goal for two consecutive hours. What should the nurse anticipate?

  1. Notifying the provider and increasing the fluid rate as directed by the protocol
  2. Giving a loop diuretic to increase urine output
  3. Decreasing the infusion to prevent fluid overload
  4. Stopping the infusion once the formula volume has been given
Show the answer and explanation

Answer: A. Notifying the provider and increasing the fluid rate as directed by the protocol

Topic: fluid resuscitation

Burn fluid resuscitation is a starting estimate and the rate is titrated to urine output (about 0.5 mL/kg/hour in adults) and perfusion. Low urine output means under-resuscitation, so fluids are increased.

Why the others are wrong

  • B – A diuretic lowers intravascular volume and can worsen shock and kidney injury.
  • C – Lowering the rate when output is low deepens hypovolemia.
  • D – Fluids continue and are adjusted to response, not stopped at a calculated total.

Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.

143Question

A client in cardiogenic shock has an intra-aortic balloon pump through the femoral artery. Which finding requires the nurse's most urgent report?

  1. The left foot is cool and pale with absent pedal pulses on the cannulated side
  2. The monitor shows augmented diastolic pressure
  3. The head of the bed is at 30 degrees with the affected leg straight
  4. Urine output has increased to 60 mL/hour
Show the answer and explanation

Answer: A. The left foot is cool and pale with absent pedal pulses on the cannulated side

Topic: IABP complications

The catheter can obstruct blood flow to the leg. A cold, pale, pulseless limb signals limb ischemia and needs immediate action. Diastolic augmentation, a straight leg with limited head elevation and improved urine output are expected.

Why the others are wrong

  • B – Diastolic augmentation shows the pump is working.
  • C – Straight leg and limited head elevation prevent catheter kinking.
  • D – Improving urine output shows better perfusion.

Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.

144Question

A day after a tornado, a woman in the shelter is tearful, trembling, has not eaten, and asks about her missing family. Which approach is best?

  1. Hold a detailed debriefing so she can describe everything that happened
  2. Tell her to stay strong for the others
  3. Urge her to talk about her feelings so she does not suppress them
  4. Ensure safety and basic needs, stay calm and present, and help her get information and contact with family
Show the answer and explanation

Answer: D. Ensure safety and basic needs, stay calm and present, and help her get information and contact with family

Topic: psychological first aid

Psychological first aid focuses on safety, basic needs, comfort, information and connection to support, without forcing disclosure or detailed debriefing.

Why the others are wrong

  • A – Forced detailed debriefing can worsen distress.
  • B – Telling her to be strong dismisses her feelings.
  • C – Pressure to talk is not required and may overwhelm.

Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.

145Question

A newly appointed charge nurse tells her mentor, 'I would rather do all the post-operative ambulation myself so I know it is done right.' Which reply by the mentor best explains why delegation is expected of a nurse leader?

  1. Delegation moves the task and your accountability for its outcome to the UAP, so you can stop checking on it
  2. Delegation is needed only on days when the unit is short-staffed
  3. A good leader delegates tasks she dislikes and keeps the ones that are quick to do
  4. Delegating suitable tasks frees you for work needing RN judgment and builds staff skills
Show the answer and explanation

Answer: D. Delegating suitable tasks frees you for work needing RN judgment and builds staff skills

Topic: purpose of delegation

Delegation allows the RN to focus on assessment, teaching and other work that requires licensed judgment, and it develops the abilities of the team. The RN delegating a task keeps accountability for appropriate delegation and supervision.

Why the others are wrong

  • A – The RN remains accountable for appropriate delegation, supervision and evaluation; accountability is not transferred.
  • B – Delegation is a routine leadership skill, not just a response to short staffing.
  • C – Tasks are delegated on the basis of the five rights of delegation, not personal preference.

Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.

146Question

After a tornado, an incident command system is activated and a nurse is assigned as the Planning Section Chief. Which task belongs to this role?

  1. Ordering and delivering generators, tents and medical supplies to the response sites
  2. Directing the teams that carry out search and rescue in the damaged areas
  3. Compiling status reports and tracking resources for the incident action plan
  4. Tracking response costs and processing pay for emergency workers
Show the answer and explanation

Answer: C. Compiling status reports and tracking resources for the incident action plan

Topic: incident command system roles

The Planning Section collects, evaluates and shares information about the incident and the status of resources, and it prepares the incident action plan with the incident commander. Other sections handle operations, logistics and finance.

Why the others are wrong

  • A – Obtaining and delivering supplies and services is a logistics function.
  • B – Directing tactical response is the work of the operations section.
  • D – Cost tracking and payment fall under finance and administration.

Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.

147Question

A client who takes high-dose aspirin for arthritis reports a constant high-pitched ringing in both ears that began two days ago. How should the nurse respond to this finding?

  1. Record it as an expected age-related change and continue the visit
  2. Report it promptly as a possible early sign of salicylate toxicity
  3. Teach the client to clear the ears with cotton-tipped swabs
  4. Reassure the client that ringing in both ears is always harmless
Show the answer and explanation

Answer: B. Report it promptly as a possible early sign of salicylate toxicity

Topic: tinnitus as a drug toxicity cue

Ringing in the ears (tinnitus) is an early sign of salicylate toxicity, along with hearing changes, nausea and rapid breathing. New tinnitus in a client on high-dose aspirin needs to be reported so the dose can be reviewed.

Why the others are wrong

  • A – New ringing in a client on high-dose aspirin cannot be assumed to be age-related.
  • C – Swabs do not treat tinnitus and can injure the canal or push wax inward.
  • D – Ringing can signal drug toxicity; telling the client it is harmless is unsafe.

Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.

148Question

A resident with dementia has a signed advance directive declining resuscitation. At a family conference, the daughter demands full resuscitation while the son supports the directive. Which statement by the nurse is best?

  1. "You two need to agree before we can proceed."
  2. "The doctor will decide because your mother cannot."
  3. "Let's review together what your mother wrote and told us she wanted, and how we can honor it."
  4. "We will follow the child who visits most often."
Show the answer and explanation

Answer: C. "Let's review together what your mother wrote and told us she wanted, and how we can honor it."

Topic: Family conference and advance care planning

An advance directive records the resident's own wishes and guides decisions when capacity is lost. Staff facilitate the family conference, focus on the resident's values and refer to the directive while supporting the family's emotions.

Why the others are wrong

  • A – Requiring agreement ignores the directive and prolongs conflict.
  • B – Handing over the decision ignores the written wishes.
  • D – Visit frequency is not a basis for decisions.

Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.

149Question

A client is in cardiac arrest in the emergency department and the spouse asks to remain in the room. Which response is best?

  1. Explain that policy requires family to wait outside
  2. Offer the option and assign a staff member to stay with the spouse, explain what is happening and support them
  3. Allow the spouse to stay only if the spouse signs a waiver
  4. Allow the spouse to stay but not to be told what is happening
Show the answer and explanation

Answer: B. Offer the option and assign a staff member to stay with the spouse, explain what is happening and support them

Topic: family presence during resuscitation

Professional organizations support offering family presence during resuscitation when it is feasible, with a designated person to prepare, explain and support the family member.

Why the others are wrong

  • A – Blanket exclusion ignores evidence supporting family presence.
  • C – A waiver is not required and adds a barrier.
  • D – Withholding information increases distress; a support person should explain.

Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.

150Question

A client with diabetes is shaky, sweaty, and confused. Blood glucose is 52 mg/dL, and the client can swallow. What should the nurse do first?

  1. Give 15 g of fast-acting carbohydrate
  2. Give regular insulin
  3. Recheck the glucose in one hour
  4. Serve a full meal
Show the answer and explanation

Answer: A. Give 15 g of fast-acting carbohydrate

Topic: Hypoglycemia, rule of 15

A blood glucose level below 70 mg/dL indicates hypoglycemia. Because the client is conscious and able to swallow safely, the immediate priority is raising blood glucose using the Rule of 15 by administering 15 grams of fast-acting carbohydrates.

Why the others are wrong

  • B – Insulin lowers blood glucose further, which could cause fatal neuroglycopenia.
  • C – Rechecking in one hour delays critical care; recheck blood glucose after 15 minutes.
  • D – Full meals contain fats and proteins that delay the absorption of necessary simple sugars.

Remember: Rule of 15: Give 15 grams of fast carbs, recheck in 15.

Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.

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