A nurse assesses a patient who has ulcerative colitis and severe diarrhea.
Which assessment would the nurse complete first?

Choice A rationale

Numbness and tingling around the mouth, or perioral paresthesia, is a classic sign of hypocalcemia, not a symptom to be addressed with mouth care. Offering mouth care would not address the underlying physiological issue, which is a potential disturbance in calcium levels due to accidental removal of or damage to the parathyroid glands during thyroidectomy, a serious and life-threatening complication.

Choice B rationale

Assessing for orientation would be an inappropriate action because the patient's symptoms are physical, not neurological, and do not suggest a change in mental status. The numbness and tingling are a specific finding pointing to a possible parathyroid gland injury and subsequent hypocalcemia. The nurse must prioritize assessment and intervention related to this critical electrolyte imbalance.

Choice C rationale

Muscle twitching, or neuromuscular excitability, is a hallmark sign of severe hypocalcemia. The numbness and tingling around the mouth are early indicators, and checking for muscle twitching, such as Chvostek's or Trousseau's sign, would further confirm the suspected diagnosis. This assessment is a critical and immediate step to evaluate the severity of the electrolyte imbalance and guide appropriate intervention.

Choice D rationale

Loosening the dressing is an action for a patient experiencing symptoms of a hematoma or airway compression, such as difficulty breathing or swelling. The patient's symptom of perioral paresthesia is related to a metabolic disturbance (hypocalcemia) and is not a sign of physical compression. Therefore, loosening the dressing would not alleviate this symptom and is an incorrect intervention.

Choice A rationale

Regular human insulin is a short-acting insulin with a peak effect typically occurring 2 to 4 hours after administration. A blood glucose of 175 mg/dL is elevated, but the risk of hypoglycemia is greatest at the peak of the insulin's action. The nurse should assess for hypoglycemia at this time to prevent a potentially dangerous drop in blood glucose.

Choice B rationale

Regular insulin should be administered approximately 30 to 60 minutes before a meal to allow the insulin to begin its effect and to coincide with the postprandial rise in blood glucose. Injecting it just 20 minutes before breakfast may not be sufficient for the insulin to peak in time to effectively manage the blood sugar from the meal.

Choice C rationale

Regular insulin is typically administered subcutaneously. Intravenous (IV) push administration is reserved for emergency situations, such as diabetic ketoacidosis, under strict hospital protocols, as it can cause a rapid and dangerous drop in blood glucose, leading to severe hypoglycemia. It is not an appropriate routine action for managing a patient with a blood glucose of 175 mg/dL.

Choice D rationale

Detemir is a long-acting insulin and should never be mixed with other insulins in the same syringe. Mixing insulins can alter their pharmacodynamics, potentially affecting the onset, peak, and duration of each insulin. This could lead to unpredictable blood glucose control and an increased risk of hypoglycemia.