The nurse obtains a fingerstick blood glucose level using bedside lancet/glucose meter equipment 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?

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

Document the glucose reading in the electronic medical record as the only action needed.

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

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

Answer and Explanation

The Correct Answer is A

Choice A reason: This is the correct choice. A blood glucose level of 56 mg/dL indicates hypoglycemia, and the immediate priority is to raise the blood sugar level. Non-diet carbonated soda can provide a quick source of sugar.
Choice B reason: Documenting the reading is important but does not address the immediate need to correct the low blood sugar.
Choice C reason: While confirming the reading with a laboratory test is a good practice, it is not the first action to take when dealing with hypoglycemia.
Choice D reason: Administering insulin would be contraindicated as it would lower the blood sugar even further.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Not crying if parents return and leave again may indicate the child has moved past the initial protest stage but does not necessarily indicate despair.
Choice B reason: This is the correct choice. Lying quietly in bed can be a sign of the despair stage, where the child has given up hope of the parents' return and appears withdrawn.
Choice C reason: Screaming and crying when parents leave is characteristic of the protest stage, not the despair stage.
Choice D reason: Appearing happy and content with staff may indicate the child has reached the detachment stage, which follows despair and involves the child forming new attachments.

A. Apply a heat pack to the bridge of the nose. B. Lightly suction blood from nares and mouth. C. Have the child tilt her head forward. D. Have the child sit upright.

Correct Answer is C

Explanation

Choice A reason: Applying a heat pack to the bridge of the nose is not recommended as it may increase blood flow and worsen the bleeding.
Choice B reason: Lightly suctioning blood from nares and mouth is not typically necessary and could be uncomfortable for the child.
Choice C reason: This is one of the correct choices. Tilting the head forward prevents blood from flowing down the throat, which can cause nausea or vomiting.
Choice D reason: This is one of the correct choices. Sitting upright reduces blood pressure in the veins of the nose and may help slow the bleeding.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse obtains a fingerstick blood glucose level using bedside lancet/glucose meter equipment 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A group of children on one hospital unit are all suffering from separation anxiety. Which child is experiencing the "despair" stage of separation anxiety?

Correct Answer is B

Explanation

The nurse in a school clinic is caring for a 7-year-old girl who comes in for epistaxis. The nurse will initiate which of the following interventions? (Select the 2 responses that apply)

Correct Answer is C

Explanation

An 17-year-old with a rash and itching in the groin area is concerned that he has contracted a sexually transmitted disease and does not want his parents to find out. The nurse's best response is:

A 6-year-old child has been sent to the school nurse for wetting her pants three times in the past 2 days. The nurse should recommend that this child be evaluated for which complication first?

The nurse obtains a fingerstick blood glucose level using bedside lancet/glucose meter equipment 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?

Which foods would the nurse recommend to the mother of a 2-year-old with anemia?

What is the highest priority nursing diagnosis for a pediatric client with a third-degree circumferential burn of the right arm?

The nurse is teaching a child experiencing chronic renal failure about his diet. The nurse should discuss which of the following dietary recommendations?

In planning care, the nurse recognizes that which child should have the most difficulty with separation from family during hospitalization?

A nurse is planning care for a child with hyponatremia. The nurse, delegating care of this child to a new RN on the pediatric unit, cautions the new nurse to be especially alert for which condition in the child?