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
Explanation
Choice A rationale
Checking blood pressure does not directly address the faint pulses and cool foot. While hypotension could contribute to peripheral perfusion issues, the signs described more likely indicate compartment syndrome, which requires urgent action.
Choice B rationale
Repositioning the leg might provide some comfort but does not alleviate the potential compartment syndrome. Elevation could worsen ischemia by reducing arterial blood flow.
Choice C rationale
Compartment syndrome is a medical emergency caused by increased pressure within a muscle compartment. This pressure compromises circulation and tissue viability. The nurse must notify the health care provider immediately to prevent permanent damage.
Choice D rationale
Assessing the incision for redness delays addressing the critical signs of potential compartment syndrome. Redness indicates infection, but faint pulses and a cool extremity necessitate more urgent evaluation.
Correct Answer is A
Explanation
Choice A rationale
X-rays are commonly used to diagnose osteoarthritis as they effectively visualize joint space narrowing, osteophyte formation, and subchondral sclerosis, which are characteristic of OA. These imaging findings assist in confirming the diagnosis and assessing disease progression.
Choice B rationale
Lithography is not a diagnostic tool used for OA. It primarily refers to a printing method and has no relevance to imaging joints affected by osteoarthritis or diagnosing the condition scientifically.
Choice C rationale
Ultrasound can visualize soft tissues but is not routinely used for OA diagnosis. It does not provide the detailed assessment of joint degeneration seen in X-rays, making it less appropriate for identifying OA-related changes.
Choice D rationale
Echocardiograms are used to assess heart function and have no application in diagnosing osteoarthritis. They are irrelevant in imaging joint structures or evaluating degenerative joint diseases scientifically. .
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