A nurse is caring for a client who has an early morning blood glucose level of 58 mg/dL. The client has a prescription for insulin aspart daily before breakfast. Which of the following actions should the nurse take first?

Call for the client's breakfast.

Recheck the blood glucose in 15 min.

Administer insulin aspart.

Give the client 120 mL (4 oz) of orange juice.

Answer and Explanation

The Correct Answer is D

A. Call for the client's breakfast:
The hypoglycemia must be treated immediately before offering a full meal.

B. Recheck the blood glucose in 15 min:
This is done after treating hypoglycemia, not before.

C. Administer insulin aspart:
Insulin should not be given when blood glucose is low, as it would worsen hypoglycemia.

D. Give the client 120 mL (4 oz) of orange juice:
The first step in treating hypoglycemia (BG <70 mg/dL) is to give a fast-acting carbohydrate, such as juice.

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Correct Answer is B

Explanation

A. "I will not take aspirin for 1 week following this procedure."
Aspirin does not affect mammogram results, and there's no restriction post-procedure.

B. "I will not apply deodorant before this procedure."
Deodorants can appear as calcifications on a mammogram and interfere with results.

C. "I will not engage in physical activity for 2 days..."
There are no activity restrictions following a mammogram.

D. "I will not eat or drink 8 hours before this procedure."
Fasting is not required for a mammogram.

A. A client who is 4 days postpartum and has lochia serosa B. A client who is 3 days postpartum and has not had a bowel movement since prior to admission C. A client who is 1 day postpartum and has not voided in 8 hr D. A client who is 2 days postpartum and whose fundus is 2 to 4 cm below the umbilicus

Correct Answer is C

Explanation

A. A client who is 4 days postpartum and has lochia serosa
This is an expected finding in the healing process.

B. A client who is 3 days postpartum and has not had a bowel movement
Common postpartum; not urgent unless severe discomfort or obstruction is present.

C. A client who is 1 day postpartum and has not voided in 8 hr
Urinary retention increases the risk of uterine atony and postpartum hemorrhage-must be addressed urgently.

D. A client whose fundus is 2–4 cm below the umbilicus on day 2
Normal involution of the uterus; not concerning.

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A nurse is caring for a client who has an early morning blood glucose level of 58 mg/dL. The client has a prescription for insulin aspart daily before breakfast. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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