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

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Correct Answer is A

Explanation

Choice A reason: A third-degree circumferential burn can compromise blood flow, posing an immediate risk for altered tissue perfusion, which can lead to tissue necrosis and limb loss.

Choice B reason: While impaired physical mobility is a concern, it is not as immediately life-threatening as altered tissue perfusion.

Choice C reason: Nutritional needs are important for healing, but the immediate threat to life from a third-degree burn is the risk for altered tissue perfusion.

Choice D reason: Fluid imbalance is a significant concern due to the potential for burn-induced edema and dehydration; however, the most immediate life-threatening issue is altered tissue perfusion.

A. The nurse will call the patient weekly to monitor the patient's blood pressure and symptoms. B. The patient will take up to 4 nitroglycerine tablets sublingually for chest pain. C. The nurse will encourage the patient to walk thirty minutes every day. D. The patient will record episodes of angina and self-management for one week.

Correct Answer is D

Explanation

Choice A reason: While monitoring blood pressure and symptoms is important, it is not a self-management outcome.
Choice B reason: Taking up to 4 nitroglycerine tablets may be part of the treatment plan, but it is not an outcome.
Choice C reason: Encouraging daily exercise is good, but it does not address the management of chest pain on exertion.
Choice D reason: This is the correct choice. Recording episodes of angina and self-management strategies provides valuable information for adjusting treatment and empowering the patient.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

Explanation

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Correct Answer is D

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