The nurse obtains a fingerstick blood glucose using a bedside glucose meter for a client with a prescribed sliding scale insulin protocol. The meter indicates 56 mg/dL (3.12 mmol/L). Which intervention should the nurse implement first?

Document the glucose reading in the electronic medical record (EMR) 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.

Give the client six ounces (180 mL) of non-diet carbonated soda and instruct the client to drink it entirely.

Answer and Explanation

The Correct Answer is D

Choice A reason: Documentation is important but not the priority when the client is hypoglycemic. Immediate treatment is required to prevent complications.
Choice B reason: Sending a specimen for lab confirmation delays treatment and is not necessary when hypoglycemia is confirmed by a reliable bedside meter.
Choice C reason: Administering insulin would worsen hypoglycemia and is contraindicated at this glucose level.
Choice D reason: Administering a fast-acting carbohydrate is the first-line intervention for hypoglycemia. Non-diet soda provides rapid glucose absorption to correct the low blood sugar.

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Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason: APTT is essential for monitoring the anticoagulant effect of heparin. Regular checks help ensure therapeutic levels are maintained while minimizing bleeding risk.

Choice B reason: Electrocardiographic changes, particularly ST-segment resolution and T-wave inversion, are key indicators of successful reperfusion. Continuous ECG monitoring helps detect re-occlusion or arrhythmias.

Choice C reason: Recurrence of chest pain may signal failed reperfusion or new ischemic events. It is a critical symptom that requires immediate evaluation.

Choice D reason: PT is primarily used to monitor warfarin therapy, not heparin. It is less relevant in this context and does not provide actionable data for heparin adjustment.

Choice E reason: The groin access site, typically used for catheter-based interventions, must be monitored for signs of bleeding, hematoma, or infection, especially post-thrombolysis.

A. Record the observations and check the limb every 15 minutes. B. Release the traction and notify the healthcare provider. C. Notify the healthcare provider of the assessment findings. D. Administer a PRN pain medication routinely as prescribed.

Correct Answer is C

Explanation

Choice A reason: Documenting and monitoring are important, but delaying intervention in the presence of signs of compartment syndrome can lead to irreversible damage.
Choice B reason: Releasing traction without provider direction may be unsafe and is not the nurse’s first independent action.
Choice C reason: Notifying the healthcare provider immediately is critical. Severe pain, discoloration, and blanching suggest compromised circulation, possibly compartment syndrome, which requires urgent evaluation and intervention.
Choice D reason: Administering pain medication may mask symptoms and delay necessary treatment. Pain unrelieved by medication is a red flag for ischemia.

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The nurse obtains a fingerstick blood glucose using a bedside glucose meter for a client with a prescribed sliding scale insulin protocol. The meter indicates 56 mg/dL (3.12 mmol/L). Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Ten hours after successful thrombolysis for ST elevation myocardial infarction (STEMI), a client is receiving lidocaine and heparin infusions. Which assessment(s) should the nurse monitor regularly during the reperfusion period? Select all that apply.

Correct Answer is ["A","B","C","E"]

Explanation

A client has a leg cast following an open reduction for a fractured tibia. Approximately two hours after returning to the unit, the client reports severe pain in the affected extremity, and the nurse observes that the limb is blue and blanched. Which action should the nurse perform first?

Correct Answer is C

Explanation

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