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 B
Explanation
Choice A rationale: Recording the amount of daily wound drainage is important, but addressing the hemodynamic instability takes precedence in this situation. Choice B rationale: Replacing fluids intravenously based on intake and output is crucial to address the client's hypotension and potential dehydration.
Choice C rationale: Assessing skin condition and turgor for breakdown is important but may not address the immediate hemodynamic instability.
Choice D rationale: Turning every 2 hours around the clock from side-to-side is a general nursing intervention but does not directly address the client's hemodynamic instability.
Correct Answer is B
Explanation
Choice A rationale: Scheduling educational leave for all staff may be challenging and could disrupt the unit's operations.
Choice B rationale: Asking two staff members to attend and report what they learned to the unit's staff is a practical approach to disseminating the information without disrupting the entire staff.
Choice C rationale: Offering the program at three different times may still be challenging for staff with varying schedules, and it may not be the most efficient way to share the information.
Choice D rationale: Encouraging the education department to schedule the program at a convenient time is reasonable, but it may not guarantee that all staff can attend, and it may delay the dissemination of important information.
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