The nurse has reviewed the Provider Prescriptions at 1045.
Which of the following actions should the nurse perform first?
Apply dressing to the foot wound.
Administer regular insulin 4 units subcutaneously x 1 dose.
schedule an appointment with an ophthalmologist.
Consult an outpatient wound care specialist.
The Correct Answer is B
Rationale for Correct Choice
- Administer regular insulin 4 units subcutaneously x 1 dose: The client’s blood glucose is significantly elevated at 250 mg/dL and they are showing signs of hyperglycemia (polyuria, weight loss, nausea). Administering insulin addresses an immediate metabolic imbalance and helps prevent complications such as diabetic ketoacidosis.
Rationale for Incorrect Choices
- Apply dressing to the foot wound: Although the wound requires care, it is not the most urgent issue. Delaying insulin administration in a hyperglycemic client with systemic symptoms could increase the risk of metabolic crisis. Wound care can follow stabilization.
- Schedule an appointment with an ophthalmologist: While ophthalmologic evaluation is essential for clients with diabetes, this is a non-urgent referral and can be scheduled after acute needs like hyperglycemia and wound care are addressed.
- Consult an outpatient wound care specialist: Coordinating specialized wound care is important for infection control and healing, but it is not time-sensitive. The priority is addressing the elevated blood glucose level first to stabilize the client's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Excessive intake of bicarbonate: Excessive intake of bicarbonate would more lead to metabolic alkalosis, not respiratory alkalosis. Respiratory alkalosis is caused by excessive exhalation of carbon dioxide, not by intake of bicarbonate.
B. Acute respiratory distress syndrome (ARDS): ARDS generally leads to respiratory acidosis due to impaired gas exchange and retention of carbon dioxide, not respiratory alkalosis.
C. Hyperventilation: Hyperventilation is the most common cause of respiratory alkalosis. It leads to excessive exhalation of carbon dioxide, causing a decrease in blood carbon dioxide levels and an increase in blood pH.
D. Kyphosis: Kyphosis, a spinal deformity, could affect lung expansion but is not a direct cause of respiratory alkalosis. It might lead to other respiratory issues, but it does not primarily increase the risk of alkalosis.
Correct Answer is D
Explanation
A. Oral temperature 37.8° C (100.0° F): A mild fever (37.8° C) could be a normal response to trauma or stress, especially following casting. It does not necessarily indicate an urgent issue, but it should be monitored, particularly if it increases or persists.
B. Client can wiggle their toes: The ability to move the toes is a positive sign that the neurovascular function of the extremities is intact. This is reassuring and indicates that circulation and nerve function are being maintained.
C. Feet warm to the touch: Warm feet suggest that there is adequate blood circulation to the extremities. This is a positive finding and does not require intervention unless other signs of complications arise.
D. Pedal pulses +1: A +1 pulse indicates weak pulses, which is concerning after casting. It may be a sign of reduced circulation, and the nurse should assess for further complications such as compartment syndrome, which can result in inadequate blood flow and tissue damage.
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