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    Nightdale College HESI Pharmacology RN Proctored Exam

    A client reports confusion and blurred vision after receiving a dose of glipizide. Which action should the nurse implement?

    Explanation & Rationale

    Choice A reason: Performing a neurological exam is not the priority action in this situation. Confusion and blurred vision are signs of hypoglycemia, which is a low blood sugar level. Glipizide is a medication that lowers blood sugar by stimulating the pancreas to produce more insulin. The nurse should first confirm the blood sugar level before performing any other assessments or interventions.Choice B reason: Obtaining a fingerstick blood glucose is the best action in this situation. This is a quick and easy way to measure the blood sugar level and determine if the client is experiencing hypoglycemia. The nurse should use a glucometer and a lancet to prick the client's finger and obtain a drop of blood. The nurse should compare the result with the normal range and follow the hypoglycemia protocol.Choice C reason: Administering glucagon intramuscularly is not the first action in this situation. Glucagon is a hormone that raises blood sugar by stimulating the breakdown of glycogen in the liver. It is used as an emergency treatment for severe hypoglycemia, when the client is unconscious or unable to swallow. The nurse should only administer glucagon after confirming the blood sugar level and trying oral glucose first.Choice D reason: Measuring the client's vital signs is not the priority action in this situation. Vital signs include blood pressure, pulse, respiration, and temperature. They can provide information about the client's overall health and stability, but they are not specific to hypoglycemia. The nurse should focus on the blood sugar level, which is the most relevant indicator of hypoglycemia.

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