A nurse is caring for a client who has type 1 diabetes mellitus. The nurse misread the client’s morning fasting blood glucose level as 210 mg/dL instead of 120 mg/dL and administered the insulin dose appropriate for reading over 200 mg/dL. Which of the following actions should the nurse identify as the priority?
Notify the nurse manager.
Give the client 15 to 20 g of carbohydrate.
Complete an incident report.
Check the client’s blood glucose level.
The Correct Answer is D
Choice A: Notify the nurse manager. This is an important action that the nurse should take, but not a priority. The nurse should notify the nurse manager to report the error and seek guidance on how to proceed. The nurse manager can also provide support and feedback to the nurse and help prevent similar errors in the future.
Choice B: Give the client 15 to 20 g of carbohydrate. This is a necessary action that the nurse should take, but not the priority. The nurse should give the client 15 to 20 g of carbohydrates to raise their blood glucose level and prevent or treat hypoglycemia. The nurse should choose a fast-acting carbohydrate source, such as juice, glucose tablets, or candy.
Choice C: Complete an incident report. This is a required action that the nurse should take, but not the priority. The nurse should complete an incident report to document the error and its consequences. The incident report can help identify the root cause of the error and improve patient safety and quality of care.
Choice D: Check the client’s blood glucose level. This is the priority action that the nurse should identify according to the ABCDE principle, which prioritizes interventions based on airway, breathing, circulation, disability, and exposure. The nurse should check the client’s blood glucose level to confirm the error and assess the risk of hypoglycemia, which is a low level of glucose in the blood. Hypoglycemia can cause symptoms such as sweating, trembling, confusion, and loss of consciousness. It can be life-threatening if not treated promptly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Measure the tube for insertion from the tip of the nose to the umbilicus. This is not an intervention that the nurse should take when inserting a nasogastric tube. The nurse should measure the tube for insertion from the tip of the nose to the earlobe and then to the xiphoid process, which is a more accurate way of estimating the length of the tube needed to reach the stomach.
Choice B: Place the client in a supine position. This is not an intervention that the nurse should take when inserting a nasogastric tube. The nurse should place the client in a high-Fowler’s position, which is a position with the head of the bed elevated to 90 degrees. This position can prevent aspiration, promote breathing, and allow gravity to assist with the insertion of the tube.
Choice C: Withdraw the tube if the client gags during insertion. This is not an intervention that the nurse should take when inserting a nasogastric tube. The nurse should not withdraw the tube if the client gags during insertion, as this can cause trauma to the nasal or pharyngeal mucosa and increase discomfort. The nurse should pause and allow the client to rest and breathe until gagging subsides, then resume insertion. The nurse should also provide reassurance and encouragement to the client throughout the procedure.
Choice D: Instruct the client to place his chin to his chest and swallow. This is an intervention that the nurse should take when inserting a nasogastric tube, which is a flexible tube that is inserted through the nose and into the stomach. The nurse should instruct the client to place his chin to his chest and swallow as the tube passes through the pharynx and into the esophagus. This can facilitate the insertion of the tube and prevent it from entering the trachea or causing injury to the nasal or pharyngeal mucosa.
Correct Answer is B
Explanation
Choice A: Upper left quadrant. This is not the location where the nurse should expect the client to report abdominal pain who has diverticular disease. The upper left quadrant of the abdomen contains organs such as the stomach, spleen, pancreas, and part of the colon. Abdominal pain in this area can indicate conditions such as gastritis, peptic ulcer, pancreatitis, splenomegaly, or colon cancer.
Choice B: Lower left quadrant. This is the location where the nurse should expect the client to report abdominal pain who has diverticular disease, which is a condition that involves the formation of pouches or sacs in the wall of the colon. These pouches or sacs are called diverticula, and they can become inflamed or infected, causing diverticulitis. Diverticulitis can cause abdominal pain, fever, nausea, vomiting, and changes in bowel habits. The most common site of diverticula formation and diverticulitis is the sigmoid colon, which is located in the lower left quadrant of the abdomen.
Choice C: Upper right quadrant. This is not the location where the nurse should expect the client to report abdominal pain who has diverticular disease. The upper right quadrant of the abdomen contains organs such as the liver, gallbladder, duodenum, and part of the colon. Abdominal pain in this area can indicate conditions such as hepatitis, cholecystitis, duodenal ulcer, or colon cancer.
Choice D: Lower right quadrant. This is not the location where the nurse should expect the client to report abdominal pain who has diverticular disease. The lower right quadrant of the abdomen contains organs such as the appendix, cecum, and part of the colon. Abdominal pain in this area can indicate conditions such as appendicitis, Crohn’s disease, or colon cancer.
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