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.

Nursing Test Bank

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Correct Answer is D

Explanation

A. Mononucleosis, often caused by the Epstein-Barr virus (EBV), is not primarily spread through airborne droplets like some respiratory infections. While some respiratory secretions may be involved, it is not the main transmission route.
B. Mononucleosis is not transmitted through undercooked meat. This mode of transmission is more relevant for certain foodborne illnesses but not for viral infections like EBV.
C. Mononucleosis is not transmitted through contaminated food. This route is typical for various foodborne pathogens but does not apply to EBV.
D. Mononucleosis is often referred to as the "kissing disease" because it can be transmitted through saliva. Sharing drinks, utensils, or engaging in close personal contact with someone who has the infection can spread the virus.

A. Auscultate breath sounds. B. Observe chest expansion C. Measure capillary refill D. Measure oxygen saturation

Correct Answer is D

Explanation

A. Auscultating breath sounds can provide valuable information about the presence of wheezing, crackles, or diminished breath sounds, which may indicate respiratory issues. However, while this assessment is important for understanding the underlying cause of dyspnea, it does not directly measure the patient's oxygenation status.
B. Observing chest expansion can help the nurse assess the mechanics of breathing and whether there are any restrictions in lung expansion. While this assessment is useful, it does not provide a clear indication of the patient's oxygen saturation levels or immediate need for supplemental oxygen.
C. Measuring capillary refill can give insights into peripheral perfusion and circulation, which can be affected by oxygenation. However, it is not the most direct or specific assessment for determining the need for supplemental oxygen in a patient with dyspnea.
D. Measuring oxygen saturation (using a pulse oximeter) provides a direct and objective assessment of the patient's oxygenation status. Normal oxygen saturation levels typically range from 95% to 100%. If the oxygen saturation is below the acceptable range (usually less than 92% in many clinical settings), this would indicate the need for supplemental oxygen.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a 15-year-old patient who has been diagnosed with mononucleosis. The patient asks how the infection was obtained. Which information should the nurse include when responding to the patient?

Correct Answer is D

Explanation

The patient complaints of dyspnea and the nurse is concerned the patient may need oxygen. What assessment will the nurse perform to determine if the patient needs supplemental oxygen?

Correct Answer is D

Explanation

When caring for a patient that has undergone a tonsillectomy, the nurse's priority assessment in identifying a potential complication would include?

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