A nurse administers NPH insulin to a post-op patient (2 days post-appendectomy) at 8:00 am. At 2:00 pm, the patient is found guarding his right lower abdomen, extremely lethargic but conscious, diaphoretic, and slightly combative.
The patient’s vital signs are: T=99.1, HR=80, BP=109/62, RR=18, SPO2=97%. What should the nurse do first?
Assess the patient’s blood sugar using a bedside finger stick blood glucose test.
Administer the next dose of insulin STAT.
Administer Narcan (Naloxone) STAT.
Administer 2L O2 via nasal cannula.
The Correct Answer is A
Choice A rationale:
Hypoglycemia is a critical consideration: The patient's symptoms of lethargy, diaphoresis, and combativeness, along with recent insulin administration, raise a strong suspicion of hypoglycemia (low blood sugar). Hypoglycemia can quickly progress to coma and seizures if not promptly treated, making it a high priority to assess and address.
Bedside glucose testing is rapid and reliable: A bedside finger stick blood glucose test is a quick, non-invasive, and accurate way to determine the patient's blood sugar level. It provides immediate results, allowing for prompt intervention if hypoglycemia is confirmed.
Other assessments and interventions can follow: Once hypoglycemia is ruled out or confirmed, the nurse can proceed with other assessments and interventions as needed.
Choice B rationale:
Insulin administration without blood sugar confirmation is dangerous: Administering insulin without first checking the patient's blood sugar could worsen hypoglycemia if it is already present. This could lead to severe complications, including neurological damage or even death.
Insulin timing is not a priority: While the next dose of insulin may be due, its administration is not the most urgent priority in this situation. Addressing the patient's immediate symptoms and potential hypoglycemia takes precedence.
Choice C rationale:
Naloxone is not indicated for hypoglycemia: Naloxone is an opioid antagonist used to reverse opioid overdose. It has no effect on hypoglycemia and would not be appropriate in this case.
Choice D rationale:
Oxygen therapy may not address the underlying issue: While oxygen therapy can be beneficial for patients with respiratory distress, it does not address the potential hypoglycemia in this case. If the patient's lethargy and combativeness are due to low blood sugar, oxygen therapy alone would not be sufficient treatment.
Oxygen saturation is already within normal limits: The patient's oxygen saturation (SPO2) is 97%, indicating that their oxygenation is currently adequate. Oxygen therapy would not be indicated unless there were signs of hypoxia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Fava beans do not interact with antithyroid medications and do not need to be avoided specifically for this reason. However, it's important to note that fava beans can cause a condition called favism in individuals with a certain genetic predisposition. Favism is characterized by hemolytic anemia, which is the breakdown of red blood cells. If a patient has a history of favism or is unsure of their risk, it's best to avoid fava beans while on antithyroid medication and consult with their healthcare provider.
Choice B rationale:
Shellfish does not typically interact with antithyroid medications. However, some individuals with hyperthyroidism may have co-existing allergies to shellfish. In those cases, it's important to avoid shellfish to prevent allergic reactions, but this is not due to a direct interaction with antithyroid medications.
Choice C rationale:
Foods high in purine, such as organ meats, red meat, and certain seafood, are often restricted in individuals with gout. Gout is a form of arthritis caused by the buildup of uric acid crystals in the joints. While hyperthyroidism can sometimes increase uric acid levels, there's no specific interaction between antithyroid medications and purine-rich foods. Therefore, avoiding purine- rich foods is not necessary for those on antithyroid therapy unless they have gout or a predisposition to it.
Choice D rationale:
Grapefruit and grapefruit juice can significantly interact with antithyroid medications, particularly methimazole and propylthiouracil. These medications are broken down by an enzyme called CYP3A4 in the liver. Grapefruit juice inhibits the activity of CYP3A4, which can lead to increased levels of antithyroid medications in the bloodstream. This can increase the risk of side effects from the medication, such as liver damage, bone marrow suppression, and skin reactions. Therefore, it's crucial for patients on antithyroid therapy to avoid grapefruit and grapefruit juice.
Correct Answer is A
Explanation
Choice A rationale:
Severe acidemia: A pH of 6.9 indicates severe acidemia, a condition where the blood is too acidic. Sodium bicarbonate is an alkalizing agent that can help raise the blood pH back to a normal range.
Rapid correction: Intravenous (IVP) administration of sodium bicarbonate allows for rapid correction of acidemia, which is crucial in severe cases to prevent life-threatening complications.
Buffering action: Sodium bicarbonate acts as a buffer, accepting excess hydrogen ions (H+) in the blood and converting them into water and carbon dioxide (CO2), which can be exhaled.
Specific indications: Sodium bicarbonate is typically used in cases of severe acidemia caused by metabolic acidosis, such as diabetic ketoacidosis or lactic acidosis. It may also be considered in cases of respiratory acidosis, but other interventions like ventilatory support are often prioritized.
Choice B rationale:
Calcium carbonate is not a direct treatment for acidemia: It is primarily used as an antacid to neutralize stomach acid and as a calcium supplement for bone health. While it can have a mild alkalizing effect, it is not as effective as sodium bicarbonate in rapidly correcting severe acidemia.
Choice C rationale:
Alkalemia: A pH of 7.6 indicates alkalemia, a condition where the blood is too alkaline. Administration of sodium bicarbonate in this situation would worsen the alkalemia and potentially lead to serious complications.
Choice D rationale:
Hyponatremia: Low serum sodium levels do not directly require treatment with sodium bicarbonate. Sodium bicarbonate is primarily used to address acid-base imbalances, not electrolyte imbalances.
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