The nurse is preparing a 50 mL dose of 50% dextrose IV for a patient with insulin shock. What is the appropriate method for administering the medication?

Mix the dextrose in a 50 mL piggyback for a total volume of 100 mL.

Dilute the dextrose in one liter of 0.9% normal saline solution.

Request the pharmacist to add the dextrose to a total parenteral nutrition (TPN) solution.

Administer the undiluted dextrose slowly through the currently infusing IV. .

Answer and Explanation

The Correct Answer is D

Choice A rationale
Mixing the dextrose in a 50 mL piggyback for a total volume of 100 mL is not the appropriate method for administering the medication. This would dilute the dextrose, reducing its concentration and potentially making it less effective.
Choice B rationale
Diluting the dextrose in one liter of 0.9% normal saline solution is not the appropriate method for administering the medication. This would significantly dilute the dextrose, reducing its concentration and potentially making it less effective.
Choice C rationale
Requesting the pharmacist to add the dextrose to a total parenteral nutrition (TPN) solution is not the appropriate method for administering the medication. While dextrose is often a component of TPN solutions, in this case, the patient requires a concentrated dose of dextrose to treat insulin shock.

Choice D rationale
This is the correct answer. Administering the undiluted dextrose slowly through the currently infusing IV is the appropriate method for administering the medication. This allows for the rapid administration of a concentrated dose of glucose, which is necessary to quickly raise the patient’s blood glucose level in the case of insulin shock.

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Correct Answer is A

Explanation

Choice A rationale
Testing the fluid on the dressing for glucose is the immediate action the nurse should take. Clear fluid could be cerebrospinal fluid (CSF), which is often released following spinal surgery. CSF contains glucose, so a positive glucose test would confirm it is CSF.
Choice B rationale
Replacing the dressing using a compression bandage is not the immediate action the nurse should take. While it is important to manage the drainage and prevent infection, the nurse first needs to identify what the clear fluid is.
Choice C rationale
Marking the drainage area with a pen and continuing to monitor is not the immediate action the nurse should take. While this can be part of ongoing wound care and monitoring, the nurse first needs to identify what the clear fluid is.

Choice D rationale
Documenting the findings in the electronic medical record is an important step, but it should not be the immediate action. The nurse first needs to identify what the clear fluid is, as it could indicate a complication from the surgery.

A. Inquire if the patient is experiencing any pain during urination. B. Encourage the patient to increase their intake of high-protein foods. C. Review the patient’s current food and medication allergies. D. Determine if the patient has recently experienced a fall. E. Provide instructions on how to take the patient’s temperature.

Correct Answer is ["A","C","D","E"]

Explanation

Choice A rationale
A sudden change in behavior, especially confusion and agitation, in an elderly patient could be a sign of a urinary tract infection (UTI). Pain during urination is a common symptom of UTIs.
Therefore, it is crucial to inquire if the patient is experiencing any pain during urination.
Choice B rationale

While a high-protein diet can be beneficial for some patients, there is no direct link between increased protein intake and the alleviation of confusion or agitation in elderly patients.
Therefore, this option is not a necessary immediate action for the nurse to take.
Choice C rationale
Reviewing the patient’s current food and medication allergies is important. Certain medications or foods might cause adverse reactions, including confusion and agitation. Therefore, it is crucial to review the patient’s allergies to rule out any potential allergens as the cause of the sudden change in behavior.
Choice D rationale
A recent fall could potentially lead to a head injury, which might cause confusion and agitation. Therefore, it is important to determine if the patient has recently experienced a fall.
Choice E rationale
Providing instructions on how to take the patient’s temperature is important. Fever could be a sign of an infection or other medical condition that might cause confusion and agitation.
Therefore, knowing how to accurately measure the patient’s temperature can help monitor the patient’s condition.

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The nurse is preparing a 50 mL dose of 50% dextrose IV for a patient with insulin shock. What is the appropriate method for administering the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse notices the presence of clear fluid on the surgical dressing of a patient who has just returned to the unit following lumbar spinal surgery. What immediate action should the nurse take?

Correct Answer is A

Explanation

Correct Answer is ["A","C","D","E"]

Explanation

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