Which test results require the most immediate action by the nurse?

Glycosylated hemoglobin (Hgb A1C) level of 7.5

Random plasma glucose level of 205

A blood glucose prior to the noon meal of 45

Fasting blood glucose level of 300.

Answer and Explanation

The Correct Answer is C

A.   This level indicates average blood glucose over the past 2-3 months and is higher than the target range (usually under 7% for many patients with diabetes). While this result suggests the need for adjustments in management, it is not an immediate emergency.
B.   A random plasma glucose level of 205 mg/dL indicates hyperglycemia, but it is not typically considered an immediate danger unless accompanied by symptoms of hyperglycemia. This level would warrant further monitoring and possibly an adjustment in treatment, but it doesn't require urgent intervention.
C.   A blood glucose level of 45 mg/dL indicates hypoglycemia, which is a critical condition that requires immediate action. Hypoglycemia can lead to symptoms such as confusion, seizures, or loss of consciousness, and it must be addressed quickly, usually with fast-acting carbohydrates.
D.   While a fasting blood glucose level of 300 mg/dL indicates significant hyperglycemia, it does not require immediate action like hypoglycemia does. This level indicates a need for further management but is not acutely dangerous compared to a severely low blood glucose level.

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Correct Answer is B

Explanation

A. This is not a typical preoperative instruction for retinal detachment surgery. Pupil constriction is not directly related to the procedure.
B. This is crucial to prevent further damage to the retina. Sudden head movements can exacerbate the detachment.
C. Cool compresses are not typically recommended before retinal detachment surgery. They may not have a significant impact on the condition.
D. While eye patches might be used post-operatively to protect the eyes, it's not a common preoperative instruction.

A. Scatter rugs are present in the kitchen. B. Uses a microwave for cooking. C. Handrails are present in the bathroom D. Electrical cords are placed along the walls.

Correct Answer is A

Explanation

A. This is a significant safety risk. Scatter rugs can easily be a tripping hazard, especially for individuals with decreased vision. They can slip or shift, leading to falls, which are a major concern for older adults.
B. Using a microwave is often a better option for older adults, as it reduces the need to handle pots and pans on the stovetop, which can be more hazardous for those with vision impairments. It allows for safer meal preparation.

C. Handrails provide support and stability, helping to prevent falls, especially in a room like the bathroom, where wet surfaces can create hazards. This is a positive aspect of the home environment.D
D. While placing electrical cords along the walls can minimize tripping hazards, it can still pose a risk if they are not secured properly or if they cross pathways in a way that is not visible to someone with decreased vision. However, this is generally less of a risk compared to scatter rugs.

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Which test results require the most immediate action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is talking with a client who is scheduled for surgery to repair retinal detachment. Which of the following preoperative instructions should the nurse include?

Correct Answer is B

Explanation

A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?

Correct Answer is A

Explanation

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