You determine that the fingerstick blood glucose reading for a patient with diabetes is 750 mg/dL. What is your priority action?
Immediately notify the registered nurse (RN) and the health care provider
Check the record to verify whether the patient has type 1 or type 2 diabetes
Administer prescribed sliding scale insulin
Assess the vital signs of the patient
The Correct Answer is A
Choice A reason: A blood glucose of 750 mg/dL indicates severe hyperglycemia, potentially diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS), both life-threatening. Notifying the RN and provider ensures rapid intervention, such as IV insulin and fluids, to correct glucose, acidosis, and dehydration, preventing multi-organ failure or coma.
Choice B reason: Verifying diabetes type is important but not the priority with a glucose of 750 mg/dL. Both type 1 (DKA risk) and type 2 (HHS risk) require urgent treatment for severe hyperglycemia. Delaying action for record review risks worsening metabolic decompensation, making this less urgent.
Choice C reason: Administering sliding scale insulin without provider guidance is unsafe for severe hyperglycemia (750 mg/dL), as it may be insufficient for DKA or HHS. IV insulin and fluid therapy are typically required, and acting independently risks inadequate treatment, delaying critical care and worsening patient outcomes.
Choice D reason: Assessing vital signs is useful but not the priority. Severe hyperglycemia requires immediate medical intervention to correct metabolic derangements. Vital signs may indicate shock or dehydration, but notifying the provider ensures comprehensive management, including diagnostics and treatment, addressing the root cause more effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Beta blockers are used in cirrhosis to reduce portal hypertension and variceal bleeding risk but are not a priority in acute liver failure. They do not address immediate life-threatening issues like hemodynamic instability or respiratory compromise, which are critical in acute liver failure management.
Choice B reason: Maintaining airway and stabilizing circulation is the priority in acute liver failure, as patients may develop cerebral edema, causing respiratory compromise, or coagulopathy, leading to bleeding and shock. Ensuring oxygenation and hemodynamic stability prevents multi-organ failure, addressing the most immediate life-threatening complications of liver failure.
Choice C reason: Paracentesis removes ascitic fluid in cirrhosis but is not a priority in acute liver failure, where ascites is less prominent. It does not address urgent issues like airway compromise or circulatory shock, which are critical in preventing rapid deterioration in acute liver failure.
Choice D reason: Vitamin K corrects coagulopathy from liver dysfunction but is not the priority in acute liver failure. While bleeding risk is significant, airway and circulatory stability take precedence, as respiratory failure or shock are more immediately life-threatening than correctable coagulopathy in this acute setting.
Correct Answer is B
Explanation
Choice A reason: Checking blood glucose before and after exercise is correct, as physical activity increases glucose uptake, risking hypoglycemia. Monitoring ensures safe exercise and timely interventions, reflecting proper understanding of self-management in type 2 diabetes to maintain glycemic control.
Choice B reason: Monitoring blood glucose only when feeling unwell is incorrect. Regular monitoring, regardless of symptoms, is essential in type 2 diabetes to detect asymptomatic hyperglycemia or hypoglycemia, guide treatment adjustments, and prevent complications, indicating a need for further education on consistent monitoring.
Choice C reason: Using a lancet to obtain a blood sample is standard for glucose monitoring. This technique ensures accurate readings with minimal discomfort, aligning with proper self-monitoring practices in type 2 diabetes, reflecting correct understanding of the procedure and equipment use.
Choice D reason: Recording blood glucose readings is appropriate, as it allows tracking of glycemic patterns and informs provider adjustments to therapy. This practice supports effective diabetes management and complication prevention, indicating the client understands the importance of documentation in self-care.
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