A nurse is caring for a client who has an early morning blood glucose level of 58 mg/dL. The client has a prescription for insulin aspart daily before breakfast. Which of the following actions should the nurse take first?

Call for the client's breakfast.

Recheck the blood glucose in 15 min.

Administer insulin aspart.

Give the client 120 mL (4 oz) of orange juice.

Answer and Explanation

The Correct Answer is D

A. Call for the client's breakfast:
The hypoglycemia must be treated immediately before offering a full meal.

B. Recheck the blood glucose in 15 min:
This is done after treating hypoglycemia, not before.

C. Administer insulin aspart:
Insulin should not be given when blood glucose is low, as it would worsen hypoglycemia.

D. Give the client 120 mL (4 oz) of orange juice:
The first step in treating hypoglycemia (BG <70 mg/dL) is to give a fast-acting carbohydrate, such as juice.

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Correct Answer is C

Explanation

A. "My caregiver rearranged the furniture in the living room and I ran into the couch.":
This explanation is plausible and does not necessarily indicate abuse.

B. "I take a blood thinner and I bump into things sometimes.":
Clients on anticoagulants are at higher risk of bruising from minor trauma.

C. "Please don't tell anyone you saw these; I do not want to go to a nursing home.":
Fear of reporting, secrecy, and concern over consequences are common signs of potential abuse or neglect.

D. "I don't like having to use my walker for short trips when I am in my home.":
This statement reflects a personal preference, not a red flag for abuse.

A. "You won't be able to input any data until you reset your password." B. "You can use my password on another terminal, but just this one time." C. "If you'd like to give me the data, I can enter it for you." D. "The charge nurse can log on for you and watch you input the data."

Correct Answer is A

Explanation

A. "You won't be able to input any data until you reset your password.":
Sharing passwords violates HIPAA and hospital policy. The nurse must reset their own password to maintain system security and accountability.

B. "You can use my password on another terminal, but just this one time.":
Sharing login credentials is a HIPAA violation and compromises data integrity.

C. "If you'd like to give me the data, I can enter it for you.":
Entering data under someone else’s credentials is inaccurate and illegal documentation.

D. "The charge nurse can log on for you and watch you input the data.":
Each nurse must use individual login credentials. Even supervision doesn't justify credential sharing.

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A nurse is caring for a client who has an early morning blood glucose level of 58 mg/dL. The client has a prescription for insulin aspart daily before breakfast. Which of the following actions should the nurse take first?

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