A client who has type 2 diabetes mellitus takes metformin 500 mg PO daily for blood glucose control. The client has been NPO since midnight in preparation for general anesthesia and surgery. At 0700 the client's serum glucose level is 250 mg/dL (13.9 mmol/L). Which action should the nurse implement?

Reference Range:

Fasting Blood Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

Obtain a prescription for regular insulin SUBQ per sliding scale.

Record the blood glucose results and requisition a repeat test in one hour.

Prepare to initiate a continuous IV infusion of Insulin in normal saline.

Administer the client's daily metformin tablet with a sip of water.

Answer and Explanation

The Correct Answer is A

A. Administering insulin per sliding scale is appropriate for managing elevated blood glucose in a patient who is NPO and cannot take oral hypoglycemics like metformin.

B. Repeating the test in one hour delays necessary treatment and does not address the current hyperglycemia.

C. A continuous IV infusion of insulin is more appropriate for severe hyperglycemia or critical care situations, but obtaining a sliding scale prescription is more routine in this context.

D. Administering metformin with a sip of water could be considered if the provider orders it, but typically, oral hypoglycemics are held when a patient is NPO.

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Correct Answer is D

Explanation

A. Urinary output is important but not as critical as identifying the potential source of infection.
B. A 24-hour medication history is useful but secondary to identifying an acute infection.
C. The amount of serous drainage provides information on wound healing but does not confirm infection.
D. Increased confusion in an older adult, especially with a wound present, raises concern for infection, possibly sepsis. A WBC count can help identify infection and guide further treatment.

A. Use a pulse oximeter to assess oxygen saturation. B. Advise the client to reduce the medication dose. C. Report the finding to the healthcare provider. D. Check the client's capillary glucose level.

Correct Answer is C

Explanation

A. Jaundice is not related to oxygen saturation, so using a pulse oximeter is not appropriate in this situation.
B. Reducing the dose of acetaminophen may be necessary, but this decision should be made after evaluating liver function.
C. Jaundice, characterized by yellowing of the skin, can indicate liver dysfunction, possibly due to acetaminophen overuse or toxicity. The nurse should report this finding to the healthcare provider immediately for further evaluation and management.
D. Checking capillary glucose levels is not relevant to the assessment of jaundice.

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Naxlex Comprehensive Predictor Exams

An older client who is experiencing urinary incontinence is brought to the clinic with increased confusion. The nurse observes serous drainage from a laceration on the client's left arm. Which assessment is most important for the nurse to obtain?

Correct Answer is D

Explanation

While assessing a client who takes acetaminophen for chronic pain, the nurse observes that the client's skin looks yellow in color. Which action should the nurse take in response to this finding?

Correct Answer is C

Explanation

When systematically auscultating a client's anterior breath sounds, the nurse should begin by placing the stethoscope over which location?

A client who is in shock is receiving a continuous IV infusion of a sympathomimetic dopamine. Which intervention should the nurse include in this client's plan of care?

The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL vial. Which action should the nurse perform with the remainder of the medication?

While assessing placement of a nasogastric tube (NGT), the nurse aspirates cloudy green fluid into a syringe. Which intervention should the nurse implement?

A client with myasthenia gravis receives a new prescription for pyridostigmine. Which information should the nurse obtain to prior to administering the medication?

The home care nurse has identified the nursing problem, "risk for hopelessness" for a client who is terminally ill with a life expectancy of several days. Which instruction should the nurse provide to the client's spouse?

A client is being evaluated for environmental allergies. While examining the client's nasal passage, which finding suggests to the nurse that the client is experiencing allergic rhinitis?

During the shift change report, the nurse is told that a client has a stage 2 pressure injury. Which ulcer appearance is most likely to be observed?