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: Paging a chaplain on call can be a supportive measure, but it might not address the immediate need for communication and coordination with the family.

Choice B rationale: Allowing each family member to ask a question one at a time may not be the most effective approach when dealing with multiple and repetitive questions.

Choice C rationale: Requesting the healthcare provider to speak with the family might be appropriate, but it could take time, and the immediate need is to establish effective communication.

Choice D rationale: Asking the family to identify a specific spokesperson helps streamline communication and ensures that information is conveyed more efficiently. This approach can help manage the situation and address the family's concerns collectively.

A. Hepatitis A complaining of arms and legs itching. B. Rheumatoid arthritis having trouble sleeping. C. Spinal osteomyelitis with complaint of nausea. D. Right leg cast with a tingling down the leg.

Correct Answer is D

Explanation

Choice A rationale: This is not an emergency compared to a client with a right cast leg reporting tingling on the leg.

Choice B rationale: This is not an emergency compared to a client with a right cast leg reporting tingling on the leg.

Choice C rationale: This is not an emergency compared to a client with a right cast leg reporting tingling on the leg.

Choice D rationale: This could indicate impaired circulation or nerve compression, which could lead to permanent damage or loss of limb if not treated promptly.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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