A nurse is caring for a client who has type 1 diabetes mellitus. The nurse misread the client’s morning fasting blood glucose level as 210 mg/dL instead of 120 mg/dL and administered the insulin dose appropriate for reading over 200 mg/dL. Which of the following actions should the nurse identify as the priority?

Notify the nurse manager.

Give the client 15 to 20 g of carbohydrate.

Complete an incident report.

Check the client’s blood glucose level.

Answer and Explanation

The Correct Answer is D

Choice A: Notify the nurse manager. This is an important action that the nurse should take, but not a priority. The nurse should notify the nurse manager to report the error and seek guidance on how to proceed. The nurse manager can also provide support and feedback to the nurse and help prevent similar errors in the future.

Choice B: Give the client 15 to 20 g of carbohydrate. This is a necessary action that the nurse should take, but not the priority. The nurse should give the client 15 to 20 g of carbohydrates to raise their blood glucose level and prevent or treat hypoglycemia. The nurse should choose a fast-acting carbohydrate source, such as juice, glucose tablets, or candy.

Choice C: Complete an incident report. This is a required action that the nurse should take, but not the priority. The nurse should complete an incident report to document the error and its consequences. The incident report can help identify the root cause of the error and improve patient safety and quality of care.

Choice D: Check the client’s blood glucose level. This is the priority action that the nurse should identify according to the ABCDE principle, which prioritizes interventions based on airway, breathing, circulation, disability, and exposure. The nurse should check the client’s blood glucose level to confirm the error and assess the risk of hypoglycemia, which is a low level of glucose in the blood. Hypoglycemia can cause symptoms such as sweating, trembling, confusion, and loss of consciousness. It can be life-threatening if not treated promptly.

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Correct Answer is A

Explanation

Choice A: Drinking orange juice regularly. This is a contributing factor to the client’s heartburn because orange juice is acidic and can irritate the esophageal mucosa and lower esophageal sphincter, causing reﬂux of gastric contents into the esophagus.

Choice B: Eating dinner early in the evening. This is not a contributing factor to the client’s heartburn, but rather a recommended action for the client to prevent heartburn. The client should avoid eating within 3 hours of bedtime to allow for gastric emptying and reduce the risk of reﬂux.

Choice C: Consuming low-fat meats. This is not a contributing factor to the client’s heartburn, but rather a recommended action for the client to prevent heartburn. The client should avoid high-fat foods, which can delay gastric emptying and increase intra-abdominal pressure, leading to reﬂux.

Choice D: Sleeping on a large wedge-style pillow. This is not a contributing factor to the client’s heartburn, but rather a recommended action for the client to prevent heartburn. The client should elevate the head of their bed or use a wedge pillow to create an incline that prevents gastric contents from ﬂowing back into the esophagus.

A. Docusate B. A corticosteroid medication C. Aspirin D. A bowel cathartic medication

Correct Answer is B

Explanation

Choice A: Docusate. This is not a treatment that the nurse should expect to administer to a client with an acute exacerbation of ulcerative colitis. Docusate is a stool softener that can prevent constipation and straining, but it is not indicated for ulcerative colitis.

Choice B: A corticosteroid medication. This is a treatment that the nurse should expect to administer to a client with an acute exacerbation of ulcerative colitis, which is a chronic inﬂammatory bowel disease that causes ulcers and inﬂammation in the colon and rectum. A corticosteroid medication, such as prednisone, can reduce inﬂammation, suppress the immune system, and relieve symptoms such as diarrhea, bleeding, and pain.

Choice C: Aspirin. This is not a treatment that the nurse should expect to administer to a client with an acute exacerbation of ulcerative colitis. Aspirin is a nonsteroidal anti-inﬂammatory drug (NSAID) that can relieve pain and inﬂammation, but it can also irritate the gastrointestinal mucosa and worsen ulcerative colitis.

Choice D: A bowel cathartic medication. This is not a treatment that the nurse should expect to administer to a client with an acute exacerbation of ulcerative colitis. A bowel cathartic medication, such as bisacodyl, can stimulate bowel movements and cleanse the colon, but it can also cause dehydration, electrolyte imbalance, and aggravate ulcerative colitis.

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has gastroesophageal reﬂux disease (GERD) and reports having heartburn every night. Which of the following actions should the nurse identify as a contributing factor to the client’s heartburn?

Correct Answer is A

Explanation

A nurse is reviewing the plan of care for a client experiencing an acute exacerbation of ulcerative colitis. Which of the following treatments should the nurse expect to administer?

Correct Answer is B

Explanation

A nurse is collecting data from a client who has peptic ulcer disease. Which of the following findings is a manifestation of gastrointestinal perforation?

A nurse is caring for a client who has developed a Clostridium difficile infection following antibiotic therapy. Which of the following actions should the nurse take?

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A nurse is assisting with the plan of care for a client who has hypothyroidism with myxedema. Which of the following interventions should the nurse include in the plan of care?

A nurse is collecting data from a client who has obstruction and inﬂammation of the common bile duct due to cholelithiasis. Which of the following findings is expected for this condition?

A nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if there will be a lot of pain during the procedure. Which of the following responses should the nurse make?

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