After administering the client’s 0730 prescribed dose of regular insulin per a sliding scale, which action by the practical nurse (PN) has the highest priority?
Instruct the unlicensed assistive personnel (UAP) to take the client a breakfast tray
Observe the client for pallor, diaphoresis, or fatigue
Measure the client’s vital signs and oxygen saturation
Notify the charge nurse of the dose of insulin administered
The Correct Answer is B
Choice A reason: Instructing the UAP to bring a breakfast tray ensures nutritional support but is not the highest priority. Regular insulin peaks within 2–4 hours, risking hypoglycemia if not monitored. Observing for hypoglycemic symptoms takes precedence to ensure immediate safety post-administration.
Choice B reason: Observing for pallor, diaphoresis, or fatigue is critical, as these indicate hypoglycemia, a serious risk after regular insulin administration. Insulin lowers blood glucose, and rapid drops can impair brain function or cause seizures. Monitoring for these signs ensures timely intervention, prioritizing client safety.
Choice C reason: Measuring vital signs and oxygen saturation provides general data but is less specific than monitoring for hypoglycemia symptoms. Regular insulin’s rapid action increases hypoglycemic risk, and symptoms like diaphoresis are more direct indicators, making this choice secondary to targeted observation.
Choice D reason: Notifying the charge nurse of the insulin dose is routine but not urgent. The priority is monitoring for hypoglycemia, as regular insulin can cause rapid glucose drops, leading to serious complications. Immediate client observation outweighs administrative tasks in ensuring safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Famotidine, an H2 receptor blocker, reduces gastric acid production, alleviating epigastric pain caused by acid-related conditions like gastritis or ulcers. Decreased pain indicates the drug’s effectiveness in lowering acid levels, protecting the gastric mucosa, and promoting healing, making this the primary clinical outcome.
Choice B reason: Weight loss of 3 pounds is not a direct indicator of famotidine’s effectiveness. It may result from unrelated factors like diet or illness. Famotidine targets acid reduction, not weight, so this finding is irrelevant to assessing the drug’s therapeutic impact on gastric conditions.
Choice C reason: Decreased nighttime awakenings may occur with reduced pain but are not a specific measure of famotidine’s effectiveness. Awakenings could relate to other factors, like sleep disorders. Pain reduction is a more direct indicator of the drug’s action on acid-related symptoms.
Choice D reason: A positive stool antigen test indicates Helicobacter pylori infection, not famotidine’s effectiveness. Famotidine reduces acid but does not eradicate H. pylori, which requires antibiotics. This finding is unrelated to the drug’s primary role in acid suppression and symptom relief.
Correct Answer is A
Explanation
Choice A reason: Digoxin toxicity can cause visual disturbances, like seeing yellow halos, due to its effect on retinal cone cells. The client’s comment about a yellow uniform suggests this side effect. Evaluating for toxicity, including checking serum digoxin levels, is critical, as toxicity can lead to life-threatening arrhythmias.
Choice B reason: Withholding furosemide and forcing fluids is inappropriate, as the client’s visual symptom points to digoxin toxicity, not furosemide-related issues. Furosemide causes diuresis, but no evidence suggests dehydration here. This choice does not address the likely digoxin-induced visual disturbance.
Choice C reason: Assuming the client is joking ignores a potential digoxin toxicity symptom. Visual changes, like yellow-tinted vision, are serious and require investigation, not dismissal. Administering medications without evaluation risks exacerbating toxicity, making this choice unsafe and incorrect.
Choice D reason: Additional potassium-rich foods are unnecessary, as the client is already receiving potassium chloride. The visual symptom suggests digoxin toxicity, not hypokalemia. Potassium levels may influence digoxin toxicity, but the priority is evaluating digoxin’s effects, not dietary intervention.
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