A nurse is reviewing a client’s laboratory results and notes a blood glucose result of 104 mg/dL (5.8 mmol/L). The reference range is 74 to 106 mg/dL (4.1 to 5.9 mmol/L). Which action should the nurse take?

Place the client on contact precautions.

Start a high-fiber diet.

Administer an oral steroid.

Make the client NPO.

Answer and Explanation

The Correct Answer is B

A. Place the client on contact precautions: There is no indication of an infectious process requiring isolation. A normal glucose result does not suggest the need for precautions.
B. Start a high-fiber diet: The glucose level is within the normal range but on the higher end. Promoting a high-fiber diet can help maintain stable glucose levels and support long-term glucose control, especially if the client is at risk for impaired glucose tolerance.
C. Administer an oral steroid: Steroids can raise blood glucose levels and are not indicated in this context.
D. Make the client NPO: There is no reason to restrict oral intake based on a normal glucose result. NPO status is typically ordered for specific diagnostic procedures or when there is a risk of aspiration.

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Correct Answer is B

Explanation

Choice A rationale
Withdrawing the medication into a syringe and labeling it with the client’s name is not necessary and could lead to errors or contamination.
Choice B rationale
Asking another nurse to witness the medication being discarded ensures proper documentation, accountability, and compliance with regulations.
Choice C rationale
Placing the vial with the remainder of the medication into a locked drawer does not address the need for proper documentation and labeling of the remaining medication.
Choice D rationale
Throwing the vial into the trash in the presence of another nurse is not appropriate as it does not ensure proper documentation, accountability, or safe storage of the remaining medication.

A. Begin cardiopulmonary resuscitation (CPR) and call a code. B. Ask the UAP to complete postmortem care. C. Report the client’s status to the healthcare provider. D. Notify the family of the client’s death.

Correct Answer is C

Explanation

Choice A rationale
Beginning cardiopulmonary resuscitation (CPR) and calling a code would be inappropriate in this situation because the client has a signed do not resuscitate (DNR) form. A DNR order is a legal document that instructs healthcare providers not to perform CPR if the client’s heart stops or if they stop breathing. Performing CPR would go against the client’s wishes and legal rights.
Choice B rationale
Asking the unlicensed assistive personnel (UAP) to complete postmortem care is not the immediate next step. While postmortem care is necessary, the nurse must first report the client’s status to the healthcare provider to ensure proper documentation and follow-up actions.
Choice C rationale
Reporting the client’s status to the healthcare provider is the correct action. This ensures that the healthcare provider is aware of the client’s condition and can provide further instructions or documentation as needed. It is essential to follow the proper chain of command and legal protocols in such situations.
Choice D rationale
Notifying the family of the client’s death is important, but it is not the immediate next step. The nurse should first report the client’s status to the healthcare provider to ensure that all necessary medical and legal documentation is completed before contacting the family.

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A nurse is reviewing a client’s laboratory results and notes a blood glucose result of 104 mg/dL (5.8 mmol/L). The reference range is 74 to 106 mg/dL (4.1 to 5.9 mmol/L). Which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL vial. Which action should the nurse perform with the remainder of the medication?

Correct Answer is B

Explanation

An older adult client with heart failure has a signed do not resuscitate (DNR) form in the medical record. The unlicensed assistive personnel (UAP) reports that the client is not breathing, and the nurse confirms the UAP’s findings. Which action should the nurse take next?

Correct Answer is C

Explanation

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