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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct choice. Congestive heart failure can occur in chronic renal failure due to fluid overload and the inability of the kidneys to manage fluid balance.
Choice B reason: Metabolic alkalosis is not typically a major complication of chronic renal failure; metabolic acidosis is more common due to the accumulation of acids in the body.
Choice C reason: Excessive excretion of blood urea nitrogen is not a complication; rather, in renal failure, the kidneys cannot excrete urea nitrogen effectively.
Choice D reason: Hypokalemia (low potassium) can occur, but it is not as major a complication as congestive heart failure in the context of chronic renal failure.
Correct Answer is A
Explanation
Choice A reason: Asymmetrical gluteal folds may indicate DDH due to uneven positioning of the hips.
Choice B reason: A positive Babinski test is normal in infants and is not specifically associated with DDH.
Choice C reason: A one-sided limp is not observable in newborns, as they are not yet walking.
Choice D reason: A positive Kernig sign is indicative of meningitis, not DDH, and is not relevant to the assessment of hip development.
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