The nurse misreads a blood glucose result as 210 mg/dL instead of 120 mg/dL on a patient with type 1 diabetes mellitus and gives sliding scale regular insulin. The nurse realizes the mistake 45 minutes later. What is the nurse’s priority action?
Contact the provider
Administer a snack with 15 grams of carbohydrates
Complete an incident report
Check the blood glucose level
The Correct Answer is D
Choice A reason: Contacting the provider is important but not the priority. The insulin overdose risks hypoglycemia, and immediate assessment of current glucose levels is critical to determine the patient’s status and guide interventions, as delays could worsen hypoglycemia, causing neurological or cardiovascular complications.
Choice B reason: Administering a carbohydrate snack assumes hypoglycemia without confirmation. Regular insulin peaks in 2-4 hours, and 45 minutes post-administration, glucose may not yet be critically low. Giving carbohydrates prematurely could cause hyperglycemia, making this less urgent than assessing actual glucose levels first.
Choice C reason: Completing an incident report is necessary for documentation and quality improvement but is not the priority in an acute situation. The immediate risk of hypoglycemia from excess insulin requires clinical action to assess and stabilize the patient before addressing administrative tasks.
Choice D reason: Checking blood glucose is the priority, as excess regular insulin risks hypoglycemia, especially in type 1 diabetes with no endogenous insulin reserve. Knowing the current glucose level guides interventions, preventing seizures or unconsciousness, and ensures timely correction of potential hypoglycemia or other metabolic imbalances.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Elevated serum albumin is not associated with portal hypertension or cirrhosis. Cirrhosis typically causes hypoalbuminemia due to impaired liver synthesis, reducing oncotic pressure and contributing to ascites, making this finding incorrect for indicating portal hypertension complications in cirrhosis.
Choice B reason: Esophageal varices, dilated veins in the esophagus, are a direct result of portal hypertension in cirrhosis. Increased portal vein pressure forces blood into collateral veins, forming varices, which risk rupture and life-threatening bleeding, making this the most indicative finding of portal hypertension.
Choice C reason: Decreased prothrombin time is not typical in cirrhosis, where coagulopathy prolongs prothrombin time due to impaired clotting factor synthesis. This finding does not reflect portal hypertension, which affects vascular dynamics, not coagulation directly, making it irrelevant to this complication.
Choice D reason: Clear yellow urine is normal and not indicative of portal hypertension. In cirrhosis, urine may darken due to bilirubin in jaundice, but this is unrelated to portal hypertension’s vascular effects, like varices, making this an incorrect finding for this complication.
Correct Answer is A
Explanation
Choice A reason: Metformin reduces blood sugar primarily by inhibiting hepatic gluconeogenesis, decreasing liver glucose production. It also enhances insulin sensitivity in peripheral tissues, reducing hyperglycemia in type 2 diabetes without causing hypoglycemia, as it does not stimulate insulin secretion, making this the accurate mechanism.
Choice B reason: Metformin does not block carbohydrate absorption in the intestine. Drugs like alpha-glucosidase inhibitors (e.g., acarbose) slow carbohydrate breakdown, but metformin primarily acts on the liver to reduce gluconeogenesis and improve insulin sensitivity, not directly affecting intestinal absorption.
Choice C reason: Metformin does not stimulate insulin release from the pancreas. This is the mechanism of sulfonylureas, which enhance beta-cell insulin secretion. Metformin works by reducing hepatic glucose output and increasing insulin sensitivity, making this statement incorrect for its mechanism of action.
Choice D reason: Metformin decreases, not increases, insulin resistance. It enhances insulin sensitivity in muscle and liver cells, improving glucose uptake and utilization. Increasing insulin resistance would worsen type 2 diabetes, making this statement incorrect, as metformin’s goal is to counteract insulin resistance.
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