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).
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Eliminating whole milk and dairy servings of ice cream is an appropriate choice for a client with cholecystitis. These foods are high in fat, and a low-fat diet is recommended for managing cholecystitis. High-fat foods can stimulate the gallbladder to contract, which can exacerbate symptoms and cause pain. By removing these high-fat items from their diet, the client is following the recommended dietary guidelines for managing cholecystitis.
Choice B reason: Eliminating citrus fruit and melon with a salt substitute does not specifically address the dietary recommendations for cholecystitis. While citrus fruits and melon are generally healthy choices, they are not high in fat and do not need to be eliminated from the diet. Additionally, using a salt substitute does not have a significant impact on cholecystitis management.
Choice C reason: Eliminating pasta with herbal butter and no meat sauce is not necessary for managing cholecystitis. Pasta itself is not high in fat, and using herbal butter instead of regular butter can be a lower-fat option. As long as the pasta dish is prepared with low-fat ingredients, it can be part of a cholecystitis-friendly diet.
Choice D reason: Eliminating canned vegetables with additional table salt does not specifically address the dietary recommendations for cholecystitis. While it is generally a good idea to limit sodium intake for overall health, this recommendation is more relevant for managing conditions like hypertension. The focus for cholecystitis management should be on reducing dietary fat rather than sodium.
Correct Answer is D
Explanation
Choice A reason: Biliary duct obstruction can cause symptoms similar to those described, such as abdominal pain and vomiting. However, the key indicators of acute pancreatitis are the elevated serum amylase and lipase levels, which are significantly higher than normal. These enzymes are typically elevated in cases of pancreatitis, making this the more accurate diagnosis.
Choice B reason: Surgical site infection could cause fever and pain, but it would not typically result in elevated serum amylase and lipase levels. These enzymes are specific to pancreatic inflammation and damage, which is characteristic of acute pancreatitis. Therefore, surgical site infection is less likely given the lab results.
Choice C reason: Hepatorenal failure involves liver and kidney dysfunction, which can present with various symptoms, including abdominal pain and vomiting. However, it does not typically cause a significant increase in serum amylase and lipase levels. These elevated levels are more indicative of pancreatic inflammation, pointing towards acute pancreatitis.
Choice D reason: Acute pancreatitis is characterized by upper abdominal pain radiating to the back, vomiting, fever, and significantly elevated serum amylase and lipase levels. These symptoms and lab results align with the diagnosis of acute pancreatitis, making it the correct choice.
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