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
Applying a warm pack is inappropriate for controlling active bleeding, as it can exacerbate blood flow to the site, worsening the hemorrhage rather than controlling it effectively.
Choice B rationale
Using a tourniquet above the bleeding site is a last-resort method typically reserved for life-threatening bleeding. It may cause complications such as nerve damage or ischemia, so other measures are prioritized first.
Choice C rationale
Direct pressure or sterile pressure dressing with elevation minimizes blood loss effectively by compressing the damaged vessels, promoting clot formation, and utilizing gravity to reduce the pressure at the wound site. It is the recommended first-line method.
Choice D rationale
Placing an ice pack on the bleeding site may reduce localized blood flow by inducing vasoconstriction but is less effective than direct pressure for stopping active hemorrhage. It is secondary to other control measures.
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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