A patient has administered regular insulin 30 minutes prior but has not received a breakfast tray. The patient is experiencing nervousness and tremors. What is the nurse's first action?
Administer a rapid acting insulin
Perform bedside glucose testing.
Notify the kitchen to deliver the tray.
Give the patient orange juice.
The Correct Answer is B
A. Administer a rapid acting insulin: Giving additional insulin would worsen hypoglycemia and could lead to serious complications. The patient’s symptoms suggest low blood glucose, so administering more insulin is unsafe and not indicated at this time.
B. Perform bedside glucose testing.: Checking the patient’s blood glucose provides objective data to confirm hypoglycemia. This allows the nurse to determine the appropriate intervention, such as administering glucose orally or intravenously, ensuring safe and targeted treatment.
C. Notify the kitchen to deliver the tray.: While providing food is important, waiting for the tray without confirming blood glucose could delay treatment of hypoglycemia. Immediate assessment of glucose is required before feeding.
D. Give the patient orange juice.: Administering juice may be appropriate if hypoglycemia is confirmed, but giving it before verifying blood glucose could mask other causes of tremors and nervousness. Assessment first ensures safe and effective intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Continue the amiodarone infusion at 1 mg/min.: Continuing the infusion despite bradycardia and hypotension could worsen hemodynamic instability. The patient is showing signs of significant adverse effects, making it unsafe to maintain the current rate.
B. Increase the rate of the amiodarone infusion to 1.5 mg/min.: Increasing the infusion would exacerbate bradycardia and hypotension, further compromising cardiac output. Higher doses are contraindicated in the presence of hemodynamic instability.
C. Decrease the rate of the amiodarone infusion to 0.5 mg/min.: Reducing the rate may slightly lessen adverse effects but does not adequately address the immediate risk posed by low heart rate and hypotension. Stopping the infusion is safer until the provider evaluates the patient.
D. Stop the infusion of amiodarone.: The patient exhibits hypotension and bradycardia, which are serious adverse effects of IV amiodarone. Stopping the infusion prevents further cardiovascular compromise while notifying the provider for further orders and possible interventions to stabilize the patient.
Correct Answer is B
Explanation
A. Gastrointestinal bleeding: Vancomycin does not typically cause GI bleeding. Its adverse effects are mostly related to infusion reactions and nephrotoxicity rather than direct irritation or ulceration of the gastrointestinal tract. Monitoring for bleeding is not a primary concern.
B. Red man syndrome: Rapid infusion of vancomycin can cause Red Man Syndrome, characterized by flushing, rash, hypotension, and pruritus due to histamine release. Administering the drug over at least 2 hours helps prevent this reaction and ensures patient safety during treatment.
C. Hypertension: Vancomycin infusion is not associated with elevated blood pressure. In fact, Red Man Syndrome can cause hypotension, not hypertension, making this option inconsistent with the known adverse effects of rapid administration.
D. Nausea and vomiting: While gastrointestinal discomfort may occasionally occur, nausea and vomiting are not the major concern related to rapid vancomycin infusion. The primary risk is histamine-mediated infusion reaction rather than direct GI effects.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.