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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Applying wrist restraints immediately is an invasive intervention that may escalate the client’s agitation and anger. Restraints are used when absolutely necessary to prevent harm, and only after other de-escalation techniques have failed. Their use may breach the least restrictive intervention principle, which prioritizes non-invasive measures first.
Choice B rationale
Engaging the client in a repetitive activity acts as a distraction and can reduce agitation by refocusing their attention. This technique aligns with dementia care principles, emphasizing non-pharmacological interventions to manage behavioral disturbances. By promoting sensory engagement, it can help mitigate aggression effectively and respectfully.
Choice C rationale
Placing the client in a seclusion room can escalate feelings of confusion, isolation, and fear, worsening agitation. Seclusion should only be a last resort for safety reasons and not a first-line intervention in dementia care. It is contraindicated unless immediate harm is likely.
Choice D rationale
Administering haloperidol without first attempting non-pharmacological interventions disregards the principle of using medications judiciously. While haloperidol may calm agitation, side effects such as sedation or movement disorders make it inappropriate as a first-line option. This choice should follow other measures.
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.
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