A nurse administers NPH insulin to a post-op patient (2 days post-appendectomy) at 8:00 am. At 2:00 pm, the patient is found guarding his right lower abdomen, extremely lethargic but conscious, diaphoretic, and slightly combative.
The patient’s vital signs are: T=99.1, HR=80, BP=109/62, RR=18, SPO2=97%. What should the nurse do first?
Assess the patient’s blood sugar using a bedside finger stick blood glucose test.
Administer the next dose of insulin STAT.
Administer Narcan (Naloxone) STAT.
Administer 2L O2 via nasal cannula.
The Correct Answer is A
Choice A rationale:
Hypoglycemia is a critical consideration: The patient's symptoms of lethargy, diaphoresis, and combativeness, along with recent insulin administration, raise a strong suspicion of hypoglycemia (low blood sugar). Hypoglycemia can quickly progress to coma and seizures if not promptly treated, making it a high priority to assess and address.
Bedside glucose testing is rapid and reliable: A bedside finger stick blood glucose test is a quick, non-invasive, and accurate way to determine the patient's blood sugar level. It provides immediate results, allowing for prompt intervention if hypoglycemia is confirmed.
Other assessments and interventions can follow: Once hypoglycemia is ruled out or confirmed, the nurse can proceed with other assessments and interventions as needed.
Choice B rationale:
Insulin administration without blood sugar confirmation is dangerous: Administering insulin without first checking the patient's blood sugar could worsen hypoglycemia if it is already present. This could lead to severe complications, including neurological damage or even death.
Insulin timing is not a priority: While the next dose of insulin may be due, its administration is not the most urgent priority in this situation. Addressing the patient's immediate symptoms and potential hypoglycemia takes precedence.
Choice C rationale:
Naloxone is not indicated for hypoglycemia: Naloxone is an opioid antagonist used to reverse opioid overdose. It has no effect on hypoglycemia and would not be appropriate in this case.
Choice D rationale:
Oxygen therapy may not address the underlying issue: While oxygen therapy can be beneficial for patients with respiratory distress, it does not address the potential hypoglycemia in this case. If the patient's lethargy and combativeness are due to low blood sugar, oxygen therapy alone would not be sufficient treatment.
Oxygen saturation is already within normal limits: The patient's oxygen saturation (SPO2) is 97%, indicating that their oxygenation is currently adequate. Oxygen therapy would not be indicated unless there were signs of hypoxia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Glipizide does not directly enhance glucose transport into the muscles. This action is primarily mediated by insulin, which increases the expression of glucose transporter proteins (GLUT4) on muscle cell membranes, facilitating glucose uptake.
While glipizide can indirectly improve glucose transport into muscles by increasing insulin levels, it's not the primary mechanism of action.
Choice B rationale:
Glipizide does not directly facilitate glucose utilization by body cells. This process also largely depends on insulin, which activates intracellular pathways that promote glucose metabolism and energy production.
Although glipizide can indirectly enhance glucose utilization by increasing insulin availability, it's not the main mechanism responsible for its glucose-lowering effects.
Choice C rationale:
Glipizide does not boost glucose levels. In fact, it has the opposite effect, lowering blood glucose levels by stimulating insulin secretion.
Elevating glucose levels would be counterproductive in diabetes management, as the goal is to maintain blood glucose within a healthy range.
Choice D rationale (correct answer):
Glipizide belongs to a class of medications called sulfonylureas, which act primarily by stimulating insulin secretion from pancreatic beta cells.
Insulin is a hormone that plays a crucial role in regulating blood glucose levels. It promotes glucose uptake by various tissues, including muscles, liver, and adipose tissue, and it inhibits glucose production by the liver.
By triggering insulin release, glipizide effectively lowers blood glucose levels. This helps to prevent the long-term complications of diabetes, such as damage to blood vessels, nerves, and organs.
Correct Answer is A
Explanation
Choice A rationale:
Severe acidemia: A pH of 6.9 indicates severe acidemia, a condition where the blood is too acidic. Sodium bicarbonate is an alkalizing agent that can help raise the blood pH back to a normal range.
Rapid correction: Intravenous (IVP) administration of sodium bicarbonate allows for rapid correction of acidemia, which is crucial in severe cases to prevent life-threatening complications.
Buffering action: Sodium bicarbonate acts as a buffer, accepting excess hydrogen ions (H+) in the blood and converting them into water and carbon dioxide (CO2), which can be exhaled.
Specific indications: Sodium bicarbonate is typically used in cases of severe acidemia caused by metabolic acidosis, such as diabetic ketoacidosis or lactic acidosis. It may also be considered in cases of respiratory acidosis, but other interventions like ventilatory support are often prioritized.
Choice B rationale:
Calcium carbonate is not a direct treatment for acidemia: It is primarily used as an antacid to neutralize stomach acid and as a calcium supplement for bone health. While it can have a mild alkalizing effect, it is not as effective as sodium bicarbonate in rapidly correcting severe acidemia.
Choice C rationale:
Alkalemia: A pH of 7.6 indicates alkalemia, a condition where the blood is too alkaline. Administration of sodium bicarbonate in this situation would worsen the alkalemia and potentially lead to serious complications.
Choice D rationale:
Hyponatremia: Low serum sodium levels do not directly require treatment with sodium bicarbonate. Sodium bicarbonate is primarily used to address acid-base imbalances, not electrolyte imbalances.
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