Breakfast trays have arrived on the unit, but the daily serum glucose level is not available on the chart of a client with type 1 diabetes mellitus. Which action should the nurse take?
Verify with client that the blood was drawn.
Check when insulin was last administered.
Perform a capillary glucose test.
Give the client the breakfast tray.
The Correct Answer is C
Choice A rationale: Verifying with the client that the blood was drawn is a good practice, but it might not provide immediate information about the current glucose level. The nurse needs a timely assessment to determine whether the client can safely receive the scheduled breakfast.
Choice B rationale: Checking when insulin was last administered is important, but it doesn't provide real-time information about the current glucose level. The nurse needs this information before deciding on breakfast administration.
Choice C rationale: Performing a capillary glucose test is a quick way to obtain current blood glucose levels, allowing the nurse to make an informed decision about administering the breakfast tray. This action is consistent with assessing the client's immediate status.
Choice D rationale: Giving the client the breakfast tray without knowing the current glucose level could be unsafe and against the prescribed plan of care. Assessing the glucose level is a necessary step before administering meals, especially in clients with diabetes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Placing an isolation cart outside the room is important, because mumps is a contagious viral infection that can be transmitted by respiratory droplets from coughing or sneezing. This intervention prevents the spread of infection and protects other clients and staff from exposure.
Choice B rationale: Instructing the child's parents about the need for transmission precautions is essential for preventing the spread of mumps to other individuals but the most important intervention is to place an isolation cart outside the room. Choice C rationale: Scheduling bedside playtime with the occupational therapist may be beneficial for the child but is not the most critical intervention in preventing transmission.
Choice D rationale: Assigning the child to a room close to the nurse's station may facilitate monitoring but does not directly address the prevention of transmission.
Correct Answer is D
Explanation
Choice A rationale: The client post triple coronary bypass with serosanguinous drainage in one chest tube requires attention but is not the highest priority based on the information provided.
Choice B rationale: The client with diabetic ketoacidosis and a blood glucose level of 195 mg/dl (10.8 mmol/L) needs immediate attention due to the elevated glucose level but the client with a pneumothorax and low oxygen saturation takes precedence.
Choice C rationale: The client with an Ileal conduit and scant blood in the drainage pouch is a concern but not as urgent as the client with diabetic ketoacidosis.
Choice D rationale: The client with a pneumothorax has a life-threatening condition that requires immediate attention. A pulse oximeter reading of 90% indicates hypoxia, which can lead to organ damage and death.
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