A patient with diabetes has been administered 38 units of NPH insulin at 7:00 AM. By 1:00 PM, the patient has been away from the nursing unit for 2 hours and missed lunch while waiting for a chest X-ray.
What is the most appropriate action for the nurse to prevent hypoglycemia?
Request that if testing is further delayed, the patient will eat lunch first.
Plan to discontinue the evening dose of insulin.
Save the lunch tray for the patient’s later return.
Send a glass of orange juice to the patient in the diagnostic testing area.
The Correct Answer is A
Choice A rationale:
Requesting that the patient eat lunch first if testing is further delayed is the most appropriate action to prevent hypoglycemia for the following reasons:
1. Timing of NPH Insulin Peak:
NPH insulin is an intermediate-acting insulin with a peak action time of 4-12 hours after administration.
In this case, the patient received NPH insulin at 7:00 AM, meaning its peak effect is likely to occur between 11:00 AM and 5:00 PM.
Delaying lunch beyond 1:00 PM significantly increases the risk of hypoglycemia as the insulin's action peaks without adequate food intake to balance glucose levels.
2. Ensuring Consistent Mealtimes:
Consistency in meal timing is crucial for managing blood glucose levels in diabetic patients. Delaying meals can disrupt the balance between insulin and glucose, leading to hypoglycemia.
Prioritizing lunch at the usual time, even amidst testing delays, helps maintain a more predictable glucose pattern.
3. Addressing Acute Hypoglycemia Risk:
Hypoglycemia is a serious complication of diabetes that can occur if blood glucose levels fall too low. Symptoms can include shakiness, sweating, dizziness, confusion, and even loss of consciousness.
Promptly addressing potential delays in food intake is essential to prevent hypoglycemia and its associated risks.
Rationales for other choices:
Choice B: Discontinuing the evening dose of insulin does not address the immediate risk of hypoglycemia due to the missed lunch. It could lead to hyperglycemia later in the day or overnight.
Choice C: Saving the lunch tray for later may not be feasible if testing is significantly delayed. It also does not prevent hypoglycemia in the immediate timeframe.
Choice D: While a glass of orange juice can provide a quick source of glucose, it is a short-term solution and does not replace a balanced meal. It could also lead to a rapid rise in blood glucose followed by a subsequent drop.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale:
Seizure precautions are necessary because:
The patient has ingested multiple drugs, some of which can lower the seizure threshold, such as benzodiazepines. Naloxone, while reversing opioid overdose, can also precipitate seizures in some individuals.
Flumazenil, used to reverse benzodiazepine overdose, can also induce seizures, especially in patients with a history of epilepsy or benzodiazepine dependence.
The potential for drug interactions and unpredictable effects of multiple drug ingestion further increases the risk of seizures. Specific seizure precautions include:
Placing the patient in a bed with padded side rails. Having oxygen and suction equipment readily available.
Keeping intravenous access open for potential administration of anticonvulsant medications. Closely monitoring the patient's neurological status for any signs of seizure activity.
Choice B rationale:
Aspiration precautions are crucial due to:
The patient's unconscious state, which impairs their ability to protect their airway.
The possibility of vomiting, which can occur as a side effect of naloxone or flumazenil administration.
The potential for aspiration of gastric contents, which can lead to serious respiratory complications, such as pneumonia. Specific aspiration precautions include:
Positioning the patient on their side in the recovery position. Continuously monitoring the patient's respiratory status.
Having suction equipment ready to clear the airway if necessary.
Considering intubation and mechanical ventilation if the patient's airway is compromised.
Choice D rationale:
Fall precautions are essential because:
The patient is unconscious and may be disoriented or uncoordinated upon regaining consciousness.
The effects of the ingested drugs, as well as the medications administered, can impair balance and coordination. Falls can result in serious injuries, such as head trauma or fractures.
Specific fall precautions include:
Keeping the bed in a low position with side rails up.
Assisting the patient with ambulation when they are able to move. Ensuring the patient's environment is free of tripping hazards.
Providing close supervision and assistance as needed.
Choice C rationale:
Suicide precautions are not routinely implemented in this scenario because:
The patient's primary presentation is drug overdose, not active suicidal ideation or attempts.
The focus of care is on addressing the immediate medical complications of the overdose and stabilization.
However, a thorough suicide risk assessment should be conducted once the patient is medically stable to determine if ongoing suicide precautions are necessary.
Correct Answer is ["A","B","D"]
Explanation
Rationale for Choice A: Nitroglycerin IV gtt, titrate for SBP > 180mmHg
Mechanism of action: Nitroglycerin is a potent vasodilator that acts primarily on veins, but also has some arterial vasodilatory effects. It relaxes vascular smooth muscle by stimulating the production of nitric oxide, which causes vasodilation. This decrease in preload (venous return to the heart) and afterload (resistance against which the heart pumps) leads to a reduction in blood pressure.
Indications: Nitroglycerin is a preferred agent for hypertensive emergencies associated with acute heart failure, acute coronary syndromes, and aortic dissection. It is also effective in hypertensive emergencies with elevated intracranial pressure.
Dosage and administration: Nitroglycerin is typically administered as an intravenous infusion, starting at a low dose and titrating up based on blood pressure response. The goal is to titrate the medication to maintain systolic blood pressure below 180 mmHg.
Contraindications: Nitroglycerin is contraindicated in patients with a known hypersensitivity to nitrates, severe hypotension (systolic blood pressure < 90 mmHg), or those who have recently used phosphodiesterase-5 inhibitors (such as sildenafil).
Monitoring: During nitroglycerin infusion, it's essential to monitor blood pressure closely, as well as heart rate, for any signs of hypotension or tachycardia.
Rationale for Choice B: Labetalol (Normodyne) 10mg IVP q 10 minutes prn for SBP >170 mmHg
Mechanism of action: Labetalol is a mixed alpha- and beta-adrenergic blocker. It blocks the effects of norepinephrine and epinephrine, leading to vasodilation and a decrease in heart rate.
Indications: Labetalol is a versatile agent that can be used in various hypertensive emergencies, including those associated with acute aortic dissection, acute coronary syndromes, and pre-eclampsia/eclampsia. It's also useful in patients with a history of asthma or chronic obstructive pulmonary disease (COPD), as it has less bronchoconstrictive effects than beta-blockers like propranolol.
Dosage and administration: Labetalol can be administered as an intravenous bolus or infusion. In this scenario, it's prescribed as a 10mg intravenous push every 10 minutes as needed for systolic blood pressure greater than 170 mmHg.
Contraindications: Labetalol is contraindicated in patients with severe bradycardia, heart block, cardiogenic shock, or decompensated heart failure.
Monitoring: During labetalol administration, it's important to monitor blood pressure, heart rate, and electrocardiogram (ECG) for any signs of bradycardia, heart block, or other arrythmias.
Rationale for Choice D: Nitroprusside (Nitropress) IV gtt titrate to keep SBP < 160 mmHg
Mechanism of action: Nitroprusside is a potent vasodilator that acts directly on both arterioles and veins. It relaxes vascular smooth muscle by releasing nitric oxide, leading to a rapid and profound decrease in blood pressure.
Indications: Nitroprusside is often reserved for hypertensive emergencies that are refractory to other agents or those that require rapid blood pressure control, such as hypertensive encephalopathy or acute aortic dissection.
Dosage and administration: Nitroprusside is administered as an intravenous infusion and titrated to the desired blood pressure response. The goal is to keep systolic blood pressure below 160 mmHg.
Contraindications: Nitroprusside is contraindicated in patients with severe renal impairment or those with increased intracranial pressure.
Monitoring: Nitroprusside therapy requires close monitoring of blood pressure, as well as monitoring for thiocyanate toxicity (a metabolite of nitroprusside) in patients with prolonged infusion or renal impairment.
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