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 {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"C"}}

Explanation

Temperature: 98.9°F

Neither Disease Process Nor Medication Use:
The temperature is within normal range and does not indicate an infection or other abnormality.

Heart Rate: 112 beats per minute

Disease Process:
The elevated heart rate (tachycardia) is most likely due to the asthma attack, which increases respiratory effort and oxygen demand. Anxiety from the attack could also contribute.

Respirations: 28 breaths per minute

Disease Process:
The elevated respiratory rate (tachypnea) is consistent with the asthma attack and respiratory distress, a hallmark of the disease process.

Blood Pressure: 130/86 mmHg

Neither Disease Process Nor Medication Use:
This value is slightly elevated but not significantly enough to be directly attributed to asthma or medication. It could be situational due to stress or anxiety.

Oxygen Saturation: 88%

Disease Process:
The low oxygen saturation is indicative of hypoxemia caused by bronchoconstriction and impaired gas exchange during the asthma attack.

A. Whole milk and dairy servings of ice cream. B. Citrus fruit and melon with a salt substitute. C. Pasta with herbal butter and no meat sauce. D. Canned vegetables with additional table salt.

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.

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Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"C"}}

Explanation

After teaching a client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Which food choices eliminated by the client indicate to the nurse that teaching has been successful?

Correct Answer is A

Explanation

A client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about dietary restrictions. In discussing fluid intake, the nurse should include which type of fluid limitation?

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

A client receiving thrombolytic infusions for treatment of an acute myocardial infarction (AMI) has which nursing problem?

A client who takes daily supplemental iron tablets for iron deficiency anemia reports feeling increasingly fatigued. Which laboratory value should the nurse review?

During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?

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?