The patient's meal has been delivered, and the nurse checks the pre-meal blood sugar, which is 40 mg/dL. The patient is clammy, diaphoretic, and non-arousable.
What should the nurse do next?
Stay with the patient, call for help, and recheck the blood glucose results.
Follow the hypoglycemia protocol and administer medication to raise the blood glucose.
Closely monitor the patient and recheck the blood glucose level 15 minutes after administering glucose.
Notify the physician immediately without taking other actions.
The Correct Answer is B
Choice A rationale
Staying with the patient and rechecking blood glucose delays immediate corrective action required for severe hypoglycemia (40 mg/dL). While safety is important, prompt treatment with glucose is the priority to prevent further complications.
Choice B rationale
Following the hypoglycemia protocol ensures immediate glucose administration, either orally, intravenously, or intramuscularly, to stabilize the patient. This is critical as glucose levels below 40 mg/dL require urgent intervention to prevent neuronal damage or coma.
Choice C rationale
Monitoring and rechecking glucose after treating is essential but not sufficient as the first action. Hypoglycemia this severe needs immediate treatment before monitoring, ensuring prompt glucose replacement to prevent worsening symptoms.
Choice D rationale
Notifying the physician without treating the hypoglycemia risks unnecessary delays. Immediate action, such as administering glucose per protocol, is vital in this emergency scenario for patient safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E","F"]
Explanation
Choice A rationale
Assessing the range of motion of a severely injured leg is not appropriate during initial evaluation. Movement can worsen the injury or disrupt stabilizing measures such as splints or dressings.
Choice B rationale
Asking the patient to stand or bear weight risks further injury and is contraindicated in cases of visible deformity or massive bleeding.
Choice C rationale
Evaluating skin color helps identify potential ischemia, vascular compromise, or inadequate perfusion. Pallor or cyanosis can indicate significant circulation issues needing urgent care.
Choice D rationale
Paresthesia (tingling or numbness) reflects nerve function and can reveal nerve damage or compromised blood flow, necessitating thorough evaluation.
Choice E rationale
Pain assessment is crucial for identifying the severity of injury and potential complications such as compartment syndrome. Pain disproportionate to the injury suggests complications.
Choice F rationale
Palpating pulses assesses blood flow, ensuring the presence of distal perfusion. Absent or weak pulses require urgent vascular intervention to prevent tissue necrosis.
Correct Answer is A
Explanation
Choice A rationale
Lispro (Humalog) is a rapid-acting insulin analog designed for mealtime glucose control. It begins action within 15 minutes, peaks in 1 hour, and lasts 2 to 4 hours. Its quick onset matches postprandial glucose spikes, enhancing glycemic control during meals and preventing hyperglycemia from carbohydrate intake.
Choice B rationale
Glargine (Lantus) is a long-acting basal insulin with no peak and prolonged action. It does not target mealtime spikes but provides steady glucose control over 24 hours. Its slow onset and constant release profile are unsuitable for immediate postprandial glucose management.
Choice C rationale
Detemir (Levemir) is a long-acting basal insulin, similar to glargine, with extended action for baseline glucose control. It lacks the rapid onset needed for mealtime management, making it inappropriate for postprandial hyperglycemia control, as observed in Lispro efficacy.
Choice D rationale
NPH (Humulin N) is an intermediate-acting insulin with delayed onset and peak activity. It supports baseline glucose regulation but fails to address mealtime glucose control promptly. Its time profile does not align with the immediate needs of postprandial hyperglycemia management.
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