The nurse is caring for a client who has a finger stick blood glucose level of 130 mg/dL (7.21 mmol/L). Prior to administering the scheduled dose of acarbose, the nurse is informed that morning meal trays will be 30 minutes late. Which action should the nurse take?Reference Range:
Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]
Notify the healthcare provider.
Administer the medication.
Hold the medication until the meal trays arrive.
Obtain another finger stick blood glucose level.
The Correct Answer is C
A. Notify the healthcare provider: Notification of the healthcare provider is not immediately necessary just because of a meal delay. The nurse can manage the situation appropriately by adjusting the medication timing to ensure patient safety without requiring immediate provider involvement.
B. Administer the medication: Acarbose should be taken with the first bite of food to effectively delay carbohydrate absorption. Administering it without food available increases the risk of hypoglycemia, especially since the glucose level is already slightly elevated but within a manageable range.
C. Hold the medication until the meal trays arrive: Acarbose must be taken with the first mouthful of food to match the timing of glucose absorption. Holding the medication until the meal arrives ensures optimal therapeutic effect and prevents unnecessary hypoglycemia.
D. Obtain another finger stick blood glucose level: Rechecking the blood glucose is unnecessary at this time. The primary concern is coordinating the medication with food intake, not monitoring glucose trends over a short 30-minute delay.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Expectorating bronchial secretions: This outcome is more closely associated with expectorants, which loosen mucus in the airways. Antitussives, by contrast, suppress the cough reflex and are not intended to increase mucus clearance or productive coughing.
B. Reports reduced nasal discharge: Reduced nasal discharge is typically an effect of decongestants or antihistamines, not antitussive medications. Antitussives target the cough reflex, not nasal secretions.
C. Able to sleep through the night: While improved sleep may result from reduced coughing, it is a secondary and nonspecific outcome. The ability to sleep could be influenced by other factors such as overall symptom relief, not necessarily the effectiveness of the antitussive alone.
D. Denies having coughing spells: Antitussives are designed to suppress the cough reflex, particularly in cases of dry, nonproductive cough. A report of no more coughing spells directly reflects the intended therapeutic effect of the medication.
Correct Answer is A
Explanation
A. Positive guaiac of stool: A positive guaiac test indicates the presence of blood in the stool, suggesting gastrointestinal bleeding. Given the client’s history of frequent ibuprofen use, which can cause gastric ulcers and GI bleeding, this is a critical finding that must be reported immediately to the healthcare provider.
B. Hemoglobin 13 g/dL (130 g/L): Although slightly below the normal reference range for males, a hemoglobin of 13 g/dL is not critically low. It suggests mild anemia but is not an urgent finding compared to evidence of active gastrointestinal bleeding.
C. Hematocrit 42% (0.42 volume fraction): A hematocrit of 42% falls within the normal reference range for a male client. Therefore, this finding is stable and does not require immediate reporting in the context of the client's current symptoms.
D. Gastric pH 2: A gastric pH of 2 is within the normal range for stomach acid levels (1.5 to 3.5). The current gastric pH suggests that their acid production is within expected limits and is not the immediate concern. This value does not indicate any acute problem by itself and would not require immediate notification of the healthcare provider.
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