A nurse is caring for a client who has type 1 diabetes mellitus.
Which of the following actions should the nurse take first when providing morning care?
Check the calibration of the glucometer.
Administer prescribed insulin.
Provide the client's breakfast.
Obtain the client's capillary blood glucose level.
The Correct Answer is D
Choice A rationale
Checking the calibration of the glucometer ensures accurate blood glucose readings. Calibration is essential to identify potential technical errors that could lead to inaccurate readings, compromising client care. However, this action is preparatory and does not directly address the immediate need to assess the client’s current glucose level for appropriate management.
Choice B rationale
Administering prescribed insulin is critical for controlling blood glucose levels in clients with type 1 diabetes. Insulin administration prevents complications like hyperglycemia or ketoacidosis. However, insulin should be administered based on the client’s current blood glucose level, which must be assessed first to ensure the correct dose and timing.
Choice C rationale
Providing breakfast is important to prevent hypoglycemia and support the client’s nutritional needs. However, breakfast timing must align with insulin administration to optimize glucose control. Assessing the client’s blood glucose level first is essential to determine whether immediate nutritional intervention is required.
Choice D rationale
Obtaining the client’s capillary blood glucose level is the first step in managing diabetes effectively. This action allows the nurse to evaluate the client’s current glucose status, guide insulin administration, and ensure safe provision of meals. Accurate glucose measurement is essential to prevent complications such as hypo- or hyperglycemia.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale
Countersigning the prescription within 72 hours is a legal requirement but does not directly verify the accuracy of the prescription during a telephone communication.
Choice B rationale
Verifying the medication name and purpose ensures accurate understanding and administration, reducing the risk of medication errors and adverse outcomes. This step is critical for patient safety.
Choice C rationale
Spelling out “B-I-D” is unnecessary and does not improve clarity. It is more effective to confirm the intended schedule “twice per day” to avoid misunderstandings.
Choice D rationale
Confirming the provider’s license number is not required during routine telephone orders and may distract from more important verifications for patient safety.
Correct Answer is A
Explanation
Choice A rationale
Autonomy refers to the client’s right to make informed decisions about their care and treatment without external coercion. Acknowledging the client’s decision to discontinue treatment supports this principle, promoting respect for individual rights and preferences.
Choice B rationale
Fidelity involves maintaining trust and honoring commitments, such as upholding professional promises to deliver care. While important, it does not directly address the client’s right to refuse treatment in this scenario.
Choice C rationale
Justice pertains to fairness and equitable distribution of resources and care. This principle focuses on broader societal and ethical considerations rather than the individual’s decision-making rights.
Choice D rationale
Beneficence is the principle of acting in the best interest of the client, promoting their well-being. While relevant, it does not specifically address respecting the client’s right to refuse treatment.
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