A hospitalized patient who is diabetic received 38 U of NPH insulin at 7:00 AM. At 1:00 PM, the patient was away from the nursing unit for 2 hours, missing the lunch delivery while awaiting a chest x-ray.
What is the best action by the nurse to prevent hypoglycemia?
Request that if testing is further delayed, the patient will eat lunch first.
Send a glass of orange juice to the patient in the diagnostic testing area.
Save the lunch tray for the patient's later return.
Plan to discontinue the evening dose of insulin.
The Correct Answer is B
The patient received 38 U of NPH insulin at 7:00 AM, and by 1:00 PM, the insulin has been active for approximately 6 hours. The patient has missed lunch, which may lead to hypoglycemia, especially with the activity of the insulin.
Sending a glass of orange juice will provide the patient with a quick source of glucose to prevent hypoglycemia. If testing is further delayed, the nurse may request that the patient be allowed to eat lunch first or save the lunch tray for later, but immediate intervention is necessary to prevent hypoglycemia. Discontinuing the evening dose of insulin is not an appropriate action and should not be considered without consulting the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should anticipate that the patient will need to collect a stool specimen. Diarrhea can be caused by various factors such as infections, inflammatory bowel disease, food intolerance, and medication side effects. Collecting a stool specimen can help identify the underlying cause of the diarrhea and guide appropriate treatment. Blood cultures, colonoscopy but barium enema may be necessary in certain cases but are not typically the first step in the diagnostic process for diarrhea.
Correct Answer is C
Explanation
Based on the assessment findings presented, the nurse would suspect a urinary tract infection (UTI). The client's symptoms of acute confusion, urinary frequency and incontinence, and elevated WBC count with bands suggest a possible infection. Dehydration or diabetic ketoacidosis could also cause confusion and fatigue, but these conditions are less likely given the normal BMP and CBC results.
Hepatitis would not typically present with these specific symptoms.
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