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: While high serum insulin levels can be indicative of insulin resistance and metabolic syndrome, they are not as directly related to cardiac risk as large waist circumference.

Choice B reason: Hyperpigmentation on neck skin folds, also known as acanthosis nigricans, can indicate insulin resistance and metabolic syndrome but is not as strong a predictor of cardiac disease as central obesity.

Choice C reason: Poor muscle tone is not a direct indicator of cardiac disease risk. It can be associated with overall health and fitness but is not as specific a risk factor for cardiac disease.

Choice D reason: Large waist circumference with central fat, also known as abdominal obesity, is a well-known risk factor for cardiovascular disease. Central fat is associated with increased risk of heart disease, hypertension, and diabetes, making it a significant indicator to monitor.

A. Haematocrit of 30% (0.30 volume fraction). B. Facial puffiness and periorbital enema. C. Further decline in level of consciousness. D. Cold and dry skin.

Correct Answer is C

Explanation

Choice A reason: A haematocrit of 30% is below the normal range and indicates anaemia, which is common in hypothyroidism. However, it does not require immediate intervention compared to a decline in consciousness.

Choice B reason: Facial puffiness and periorbital enema are common signs of hypothyroidism but do not require immediate intervention. They are more indicative of chronic, rather than acute, issues.

Choice C reason: A further decline in level of consciousness is critical and warrants immediate action. It can indicate a myxoedema coma, a severe complication of hypothyroidism that is life-threatening and requires urgent treatment.

Choice D reason: Cold and dry skin is a common symptom of hypothyroidism but does not require immediate intervention compared to a decline in consciousness.

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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?

Nursing Test Bank

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