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 D
Explanation
Choice A reason: Keeping suction equipment at bedside is important to maintain airway patency and prevent aspiration.
Choice B reason: Positioning the child upright for feedings can help prevent aspiration and is a recommended practice.
Choice C reason: Feeding slowly using specialized feeding bottles can help the infant feed effectively and safely.
Choice D reason: This is the correct choice. Breastfeeding is often possible with the use of special techniques and should not be discouraged unless specifically contraindicated.
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.
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