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 A
Explanation
Choice A rationale
Strict monitoring of intake and output in CHF patients with furosemide therapy prevents fluid overload and underhydration. Foley catheter placement accurately quantifies urine output, crucial in critically ill patients with diuretic-induced fluid shifts. This ensures precise fluid balance adjustments, improving patient outcomes.
Choice B rationale
Omitting Foley catheter placement in CHF patients risks inaccurate fluid balance monitoring. Furosemide causes frequent, unpredictable urination, complicating intake-output tracking without direct measurement. This approach undermines effective management of diuretic therapy and fluid overload prevention in critical settings. .
Correct Answer is F
Explanation
Choice A rationale
Dextrose IVP is unnecessary with hyperglycemia. It increases the glucose level further, risking complications like hyperosmolar hyperglycemic state. This treatment is reserved for severe hypoglycemia.
Choice B rationale
Glucagon raises blood glucose and is contraindicated for hyperglycemia. It is used to treat hypoglycemia, not elevated glucose levels seen here.
Choice C rationale
Holding insulin neglects hyperglycemia management, allowing complications like ketoacidosis or delayed glucose control. Insulin is necessary to address elevated blood sugar.
Choice D rationale
Calling the MD delays hyperglycemia treatment unnecessarily, as nurses can administer insulin per protocols in cases like this.
Choice E rationale
Administering 15 units of Humalog risks inducing hypoglycemia. It is an excessive dose given the glucose level of 243 mg/dL.
Choice F rationale
Administering 4 units of Humalog is an appropriate corrective dose for a pre-meal glucose of 243 mg/dL. Rapid-acting insulin efficiently reduces glucose to safer levels, aligning with treatment protocols.
Choice G rationale
Administering 9 units of Humalog risks overcorrecting hyperglycemia, potentially causing hypoglycemia, as it exceeds typical sliding scale guidelines for this glucose level.
Choice H rationale
Administering 5 units of Humalog could be reasonable for slight hyperglycemia, but it is not specifically aligned with the sliding scale dose appropriate for 243 mg/dL.
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