The nurse obtains a fingerstick blood glucose level using a bedside glucose meter from a client with a prescribed sliding scale insulin protocol. The meter indicates 56 mg/dL (3.12 mmol/L). At this time, which intervention should the nurse implement first?
Reference Range: Glucose 74 to 106 mg/dL (4.1 to 5.9 mmol/L)

Prepare the prescribed dose of rapid-acting insulin from the sliding scale instructions.

Give the client six ounces of non-diet carbonated soda and instruct the client to drink it entirely.

Collect a blood specimen by venipuncture to send to the laboratory for serum glucose analysis.

Document the glucose reading in the electronic medical record (EMR).

Answer and Explanation

The Correct Answer is B

Choice A reason: Preparing the prescribed dose of rapid-acting insulin from the sliding scale instructions is not appropriate when the client's blood glucose level is low (56 mg/dL). Administering insulin at this point could further lower the blood glucose level, potentially leading to severe hypoglycemia. The priority is to raise the client's blood glucose level to a safe range.

Choice B reason: Giving the client six ounces of non-diet carbonated soda and instructing the client to drink it entirely is the correct first intervention. The client’s blood glucose level is significantly below the normal reference range (hypoglycemia). Administering a fast-acting carbohydrate, such as non-diet soda, helps to quickly increase the blood glucose level to a safer range. This intervention addresses the immediate need to correct the hypoglycemia and prevent potential complications such as confusion, seizures, or loss of consciousness.

Choice C reason: Collecting a blood specimen by venipuncture to send to the laboratory for serum glucose analysis is not the first intervention to implement. While laboratory confirmation of blood glucose levels can be important, the immediate priority is to treat the hypoglycemia. Delaying treatment to collect a laboratory specimen could result in worsening of the client's condition. Immediate administration of a fast-acting carbohydrate should be prioritized.

Choice D reason: Documenting the glucose reading in the electronic medical record (EMR) is important but not the first priority. While accurate documentation is necessary for ongoing care, the immediate intervention should focus on treating the hypoglycemia. Once the client's blood glucose level has been stabilized, the nurse can then document the reading and subsequent interventions in the EMR.

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Correct Answer is C

Explanation

Choice A reason: Rubbing painful areas gently may provide temporary relief, but it is not a specific or effective long-term management strategy for Raynaud's disease. This advice could lead to further discomfort if not done correctly, and it does not address the primary trigger, which is cold exposure.

Choice B reason: Enrolling in a pain clinic can provide pain relief alternatives, but this is a general recommendation and not specific to the management of Raynaud's disease. While pain clinics can be helpful for chronic pain management, practical daily interventions are also crucial for this condition.

Choice C reason: Wearing gloves when handling cold items is a direct and practical way to prevent painful spasms associated with Raynaud's disease. This condition is characterized by episodes of reduced blood flow to the extremities, typically triggered by cold temperatures. By wearing gloves, the client can protect their hands from cold exposure, which helps prevent these painful spasms.

Choice D reason: Return appointments for IV pain medication are not typical for managing Raynaud's disease. Pain management for Raynaud's generally focuses on preventive measures and lifestyle adjustments to avoid triggers, rather than relying on IV medications for pain relief.

A. Central line insertion B. Nasogastric tube (NGT) insertion C. Tracheostomy placement D. Pacemaker placement

Correct Answer is C

Explanation

Choice A reason: Central line insertion is not the appropriate intervention for managing stridor in a postoperative parathyroidectomy patient. Stridor indicates airway obstruction, which requires immediate airway management, not central venous access. Inserting a central line would not address the underlying issue of compromised airway patency, and it would delay necessary interventions to secure the airway.

Choice B reason: Nasogastric tube (NGT) insertion is not the correct intervention for stridor. NGT insertion is typically used for gastrointestinal decompression or feeding, not for managing airway obstruction. In the context of a client experiencing stridor, the priority is to ensure a patent airway, not to manage gastrointestinal issues. NGT insertion could potentially exacerbate airway compromise in a client with stridor.

Choice C reason: Tracheostomy placement is the correct intervention for managing stridor in a postoperative parathyroidectomy patient. Stridor indicates a potential airway obstruction, which can be life-threatening. A tracheostomy provides a secure airway and ensures adequate ventilation. This procedure is particularly important in cases where upper airway obstruction is suspected, such as swelling or hematoma formation following neck surgery.

Choice D reason: Pacemaker placement is not relevant to managing stridor. Pacemakers are used for cardiac rhythm management and do not address airway obstruction. The immediate concern for a client with stridor is ensuring a patent airway, and pacemaker placement would not resolve the airway compromise.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who was recently diagnosed with Raynaud's disease is concerned about pain management. Which nursing instruction should the nurse provide?

Correct Answer is C

Explanation

The nurse is assessing a client who is one day postoperative parathyroidectomy and finds that the client is experiencing stridor. After notifying the healthcare provider (HCP), the nurse should prepare for which procedure:

Correct Answer is C

Explanation

Exhibits The nurse has implemented additional needed actions. Indicate the assessment data which indicate the interventions were successful and which assessment data provide no indication that the interventions were successful. Each column must have at least one answer selected.

Exhibits After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.

While completing a health assessment for a young adult female with acute appendicitis, the client informs the nurse that there is a chance that she may be pregnant. The operating team is preparing to take the client to surgery. Which intervention should the nurse implement immediately?

A nurse is developing home care instructions for a client with peripheral artery disease (PAD). Which intervention should the nurse include?

Exhibits The nurse is stabilizing the client and preparing her for surgery. Which goals should the nurse prioritize in the plan of care for the client while in the emergency department (ED)? Select all that apply.

The nurse assesses an adult client 24 hours after a bowel exploration and formation of a sigmoid colostomy. Which assessment finding should be reported to the surgeon immediately?

A client with chronic kidney disease (CKD) missed dialysis yesterday to attend a funeral. The client's spouse calls the home health nurse and reports that the client is lethargic and hard to arouse. Which instruction is most important for the nurse to provide?