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.

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Correct Answer is D

Explanation

Choice A reason: This choice might not arouse suspicion as it could be a plausible accident involving siblings.

Choice B reason: This choice also might not arouse suspicion as accidents can happen when children are playing and not being watched closely.

Choice C reason: This choice is less likely to arouse suspicion as slipping on ice is a common accident.

Choice D reason: This is the correct choice. The statement may arouse suspicion because it suggests negligence, as the caregiver left the baby unattended in a potentially dangerous situation.

A. Symptoms of infection B. Anaphylaxis C. Pain at the injection site D. Myalgia E. Hyperthermia

Correct Answer is B

Explanation

Choice A reason: While symptoms of infection are important to assess, they are not the immediate priority following vaccine administration.

Choice B reason: Anaphylaxis is a rapid, potentially life-threatening allergic reaction that can occur after vaccination, making it the priority assessment.

Choice C reason: Pain at the injection site is common and expected, but it is not as critical as assessing for anaphylaxis.

Choice D reason: Myalgia, or muscle pain, may occur after vaccination but is not the immediate priority for assessment.

Choice E reason: Hyperthermia, or elevated body temperature, could indicate an adverse reaction; however, anaphylaxis is the most urgent concern to address post-vaccination.

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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?

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Correct Answer is B

Explanation

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