At 8 a.m. the nurse is reviewing patient assignments and notes one of the patients has a current blood glucose of 264. Breakfast is routinely served at 8:30. The following orders are noted in the chart. What action should the nurse take? Accucheck before meals and at bedtime with sliding scale insulin aspart SQ: Glucose 0-150 Administer 0 units; 151-200 Administer 2 units; 201-250 Administer 4 units: 251-300 Administer 6 units: 301-350 Administer 8 units; 351- 400 Administer 10 units; >400 Notify physician.
Provide 2 units insulin aspart 50
Provide 6 units insulin aspart 50
Provide 10 units insin apart SQ
Provide 4 units insulin aspart 50
The Correct Answer is B
A. This option corresponds to the blood glucose range of 151-200. However, the patient's current blood glucose level is 264, which falls into the range of 251-300. Therefore, administering 2 units would not be appropriate in this case.
B. The patient's current blood glucose level is 264, which falls into the range of 251-300. According to the sliding scale insulin aspart orders, for this range, 6 units should be administered. This option aligns with the patient's blood glucose level and the prescribed protocol.
C. This option corresponds to the blood glucose range of 351-400. The patient's blood glucose level of 264 does not fall into this range, so administering 10 units would be excessive and potentially lead to hypoglycemia.
D. This option corresponds to the blood glucose range of 201-250. The patient's current blood glucose level is 264, which falls into the range of 251-300. Therefore, administering 4 units would not be sufficient to address the elevated blood glucose level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. Thyroid stimulating hormone (TSH): The anterior pituitary gland secretes TSH, which regulates the thyroid gland's function. Surgery on the anterior pituitary can potentially disrupt the production and regulation of TSH.
B. Prolactin: The anterior pituitary gland also produces prolactin. Surgery on the anterior pituitary can affect prolactin production.
C. Oxytocin: Oxytocin is produced by the posterior pituitary, not the anterior pituitary. Surgery on the anterior pituitary would not directly impact oxytocin production.
D. Gonadotropin hormones: These include follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which are important for reproductive function. The anteriorpituitary secretes these hormones, so surgery on the anterior pituitary can impact their production.
E. Adrenocorticotropic hormone (ACTH): ACTH is essential for the stimulation of cortisol release from the adrenal glands. The production of ACTH is regulated by the anterior pituitary, so surgery in this area can affect ACTH levels.
Correct Answer is C
Explanation
A. Flaccid muscles are associated with conditions like hypokalemia, not hypoparathyroidism. In hypoparathyroidism, there is a deficiency of parathyroid hormone (PTH), which leads to low calcium levels and can result in muscle spasms and tetany, not flaccid muscles.
B. While anorexia can occur in clients with various health conditions, it is not a specific finding associated with hypoparathyroidism.
C. Correct. Hypoparathyroidism is characterized by low levels of parathyroid hormone (PTH), which leads to low calcium levels in the blood. This can cause symptoms such as numbness, tingling, and muscle cramps, especially in the extremities.
D. A positive Chvostek's sign is associated with hypocalcemia, which can be caused by hypoparathyroidism. Therefore, a negative Chvostek's sign would not be an expected finding in a client with hypoparathyroidism.
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