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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale: While understanding staff opinions on healthcare insurance costs is valuable, being available to discuss changes in health benefits is more directly related to the implementation of the new plan.

Choice B rationale: Announcing the new plan at a special employee wellness event is important, but being available to discuss the changes on all shifts ensures that all staff members have the opportunity to understand and address their concerns.

Choice C rationale: Surveying nurses to see who wants to keep the old benefits plan may not be as effective as being available to all shifts for direct communication about the changes.

Choice D rationale: Being available to all shifts to discuss the changes in health benefits is crucial for effective communication and addressing any concerns or questions that may arise during the implementation of the new plan.

A. Telephone the nurse responsible for the error at home to report the omission of the transcription. B. Call the healthcare provider and ask if the prescription is still needed since 12 hours have elapsed since it was written. C. Notify the nursing supervisor of the previous shift's omission in not transcribing the prescription. D. Order the lab work as prescribed and follow procedures for completing an incident report.

Correct Answer is D

Explanation

Choice A rationale: This option involves contacting the nurse at home, which may not be appropriate or effective for addressing the immediate issue of the transcription omission.

Choice B rationale: Contacting the healthcare provider is important, but the nurse should first order the lab work as prescribed and complete and incident report.

Choice C rationale: Notifying the nursing supervisor of the previous shift's omission is important but the nurse should first order the lab work as prescribed.

Choice D rationale: Ordering the lab work as prescribed and following procedures for completing an incident report is the best action for the nurse to take because it ensures that the client's serum potassium levels are monitored and that the error is documented and reported.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Several nurses are elected by their peers to serve on a negotiating committee to recommend new healthcare benefits. After the new benefits plan is developed and approved, which action is most important for the nurses working on this committee to implement?

Correct Answer is D

Explanation

During a 24-hour electronic health record review of a client in acute renal failure, the nurse notices that a prescription, written 12 hours ago for every 6 hours serum potassium levels, was not transcribed by the previous shift. Which immediate action is best for the nurse to take?

Correct Answer is D

Explanation

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