A nurse assesses a patient with hypothyroidism who is admitted with acute appendicitis. The nurse notes that the patient's level of consciousness has decreased. What action does the nurse perform?
Restricts oral intake.
Monitor blood pressure every 4 hours.
Administer SQ insulin as prescribed.
Maintain a patent airway.
The Correct Answer is D
A decrease in the level of consciousness is a serious sign and could be an indication of worsening conditions. It is essential for the nurse to ensure that the patient's airway is open and clear, as a compromised airway can lead to hypoxia and a further decrease in consciousness. Therefore, maintaining a patent airway should be the nurse's priority action in this situation.
While monitoring blood pressure and restricting oral intake may be important interventions in certain situations, they are not the priority actions in this scenario. Administering SQ insulin may not be necessary for a patient with hypothyroidism and acute appendicitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
An insulin syringe is measured in units (U). The concentration of insulin is usually expressed in units per milliliter (U/mL), and the volume of the syringe is also measured in milliliters (mL), but the actual dosing of insulin is in units. It is important to use the correct syringe size and to measure the correct number of units to ensure accurate dosing of insulin.
Correct Answer is D
Explanation
When performing a self-monitoring blood glucose test, it is essential to choose the puncture site on the side of the fingertip, slightly off-center, and to rotate the puncture sites to prevent lipoatrophy and injury to the nerves and blood vessels in the finger. Puncturing the center of the fingertip can lead to pain, injury to the nerves, and tissue damage.
Options a, b, and c are correct and indicate appropriate actions during self-monitoring of blood glucose. Washing the puncture site using warm water and soap helps to reduce the risk of infection. Waiting for a minute with the arm down before puncturing the site helps to increase blood flow and make it easier to obtain a blood sample. A blood glucose result of 120 mg/dL indicates good blood sugar control within the target range for many patients with diabetes.
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