The nurse has reviewed the provider prescriptions at 1045.
Which of the following actions should the nurse perform first?
Apply dressing to foot wound.
Consult outpatient wound care specialist.
Schedule appointment with ophthalmologist.
Administer regular insulin 4 units subcutaneously x 1 dose
The Correct Answer is D
Apply dressing to foot wound: While wound care is important, managing hyperglycemia takes priority. High blood glucose impairs wound healing and increases infection risk, making insulin administration the more urgent intervention. Dressing application should follow glycemic control measures.
Consult outpatient wound care specialist: A wound care consultation is appropriate for managing a chronic ulcer, but immediate intervention is required to stabilize glucose levels. Optimizing wound care should come after initial glucose management.
Schedule appointment with ophthalmologist: Clients with diabetes require routine eye exams due to the risk of diabetic retinopathy. However, addressing hyperglycemia and preventing further infection are more urgent concerns at this time.
Administer regular insulin 4 units subcutaneously x 1 dose: The client's blood glucose is elevated (250 mg/dL), which can impair immune function and tissue healing. Lowering glucose with insulin is the priority to prevent complications such as worsening infection or ketoacidosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Temperature of 38° C (100.4° F): An elevated temperature may indicate infection, which is a potential complication of TPN due to the risk of central line-associated bloodstream infections. However, fever is not a sign of fluid volume overload.
B. Urinary output of 20 mL in the past hour: Oliguria (low urine output) is more commonly associated with dehydration or renal impairment rather than fluid volume overload. In fluid overload, urine output may initially increase if kidney function is normal.
C. +1 pedal pulses: Weak pulses can indicate poor circulation, hypovolemia, or peripheral vascular disease. In fluid overload, bounding pulses rather than weak pulses are typically observed due to increased intravascular volume.
D. S3 heart sound: An S3 heart sound (ventricular gallop) occurs when excess fluid volume causes rapid ventricular filling, leading to abnormal heart sounds. This finding is a classic sign of fluid volume overload and can indicate heart failure or significant fluid retention.
Correct Answer is A
Explanation
A. Stop the infusion: Acute hemolytic reactions can occur within minutes of starting a transfusion and are life-threatening. Symptoms such as chills, lower back pain, and nausea indicate a potential reaction, requiring immediate discontinuation of the transfusion to prevent further hemolysis and organ damage.
B. Collect a urine sample: A urine sample helps detect hemoglobinuria, a sign of red blood cell destruction, but it is not the priority. The infusion must be stopped first to prevent further complications before obtaining a urine sample for analysis.
C. Check the client's vital signs: Monitoring vital signs is essential, but the priority is stopping the transfusion to halt the reaction. Vital signs should be checked after discontinuing the infusion to assess the severity of the reaction and guide further interventions.
D. Administer oxygen to the client: Oxygen may be needed if respiratory distress occurs, but stopping the transfusion is the first step to prevent continued exposure to the incompatible blood product. Oxygen therapy should be implemented based on the client's condition after discontinuing the infusion.
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