The practical nurse (PN) reports to the charge nurse that a client who is receiving a parenteral nutrition infusion has a capillary glucose of 365 mg/dL (20.3 mmol/L). Which action should the charge nurse implement?

Determine if the client has a sliding scale insulin prescription.

Stop the infusion until the healthcare provider is notified.

Assess the client's urinary output for the previous 24 hours.

Review the client's record for a history of diabetes mellitus.

Answer and Explanation

The Correct Answer is A

Choice A reason: Determining if the client has a sliding scale insulin prescription is crucial. A sliding scale insulin regimen can help manage elevated blood glucose levels effectively. In the case of a capillary glucose of 365 mg/dL, prompt intervention is needed to prevent hyperglycaemia-related complications, and insulin administration is the most appropriate immediate action.

Choice B reason: Stopping the infusion until the healthcare provider is notified may not be the best immediate action. While it is essential to address the hyperglycaemia, halting the parenteral nutrition infusion can affect the client's overall nutritional and fluid balance. The focus should be on managing the glucose levels promptly.

Choice C reason: Assessing the client's urinary output for the previous 24 hours is important for monitoring overall fluid status and kidney function, but it does not directly address the immediate need to manage the elevated glucose levels.

Choice D reason: Reviewing the client's record for a history of diabetes mellitus can provide valuable information for long-term management and understanding the client's baseline glucose control. However, it is not the most urgent action in response to an acutely elevated capillary glucose level. Immediate intervention with insulin is needed to address the hyperglycaemia.

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Correct Answer is D

Explanation

Choice A reason: Calling the postanesthetic care unit (PACU) nurse to prepare for prolonged ventilatory support is important in certain situations. However, in this case, the client's immediate concern is the extremely high temperature, which needs to be addressed urgently.

Choice B reason: Determining if prescribed antibiotics were administered preoperatively is a standard procedure, but it is not relevant to the acute situation of muscle rigidity and extremely high temperature caused by succinylcholine. The nurse should focus on immediate cooling measures.

Choice C reason: Holding a prescription for dantrolene until the fever is reduced is not appropriate. Dantrolene is actually used to treat malignant hyperthermia, which is characterized by muscle rigidity and a high temperature. It should be administered immediately in such cases.

Choice D reason: Preparing ice packs for placement in the client's axillary area is a direct and immediate action to help reduce the client's extremely high temperature. Cooling measures are crucial to manage hyperthermia and prevent further complications.

A. Tell the client to lay on the left side to prevent the tongue from falling back into the mouth. B. Teach the client to take medication an hour before meals to enhance the swallowing reflex. C. Prepare the client and family for the future need of a gastrostomy tube for feeding. D. Encourage the client and family to provide a semi-solid diet with thick liquids.

Correct Answer is D

Explanation

Choice A reason: Telling the client to lay on the left side to prevent the tongue from falling back into the mouth is not a standard intervention for managing swallowing difficulties in Parkinson's disease. The focus should be on dietary modifications and safe swallowing techniques.

Choice B reason: Teaching the client to take medication an hour before meals to enhance the swallowing reflex is not a widely recognized intervention for managing swallowing difficulties. While timing of medication can be important, dietary adjustments are more immediately effective.

Choice C reason: Preparing the client and family for the future need of a gastrostomy tube for feeding might be necessary if swallowing difficulties progress significantly. However, it is not the first line of intervention and should be considered only after other measures have been tried.

Choice D reason: Encouraging the client and family to provide a semi-solid diet with thick liquids is the most appropriate intervention. Semi-solid and thickened liquids are easier to swallow and less likely to cause choking or aspiration, which is crucial for managing dysphagia in clients with Parkinson's disease.

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The practical nurse (PN) reports to the charge nurse that a client who is receiving a parenteral nutrition infusion has a capillary glucose of 365 mg/dL (20.3 mmol/L). Which action should the charge nurse implement?

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Naxlex Comprehensive Predictor Exams

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