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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A: Bradycardia. This is not a manifestation of gastrointestinal perforation, but rather a sign of vagal stimulation, which can occur in response to gastric distension, vomiting, or suctioning. Vagal stimulation can slow down the heart rate and lower the blood pressure.

Choice B: Hyperactive bowel sounds. This is not a manifestation of gastrointestinal perforation, but rather a sign of increased intestinal motility, which can occur in response to inﬂammation, infection, or irritation of the gastrointestinal tract. Hyperactive bowel sounds are loud, high-pitched, and frequent.

Choice C: Report of epigastric fullness. This is not a manifestation of gastrointestinal perforation, but rather a sign of delayed gastric emptying, which can occur in response to gastric outlet obstruction, gastroparesis, or pyloric stenosis. Epigastric fullness is a feeling of pressure or discomfort in the upper abdomen after eating.

Choice D: Severe upper abdominal pain. This is a manifestation of gastrointestinal perforation, which is a life-threatening complication of peptic ulcer disease. Peptic ulcer disease is a condition that causes erosion and ulceration of the mucosal lining of the stomach or duodenum. If the ulcer penetrates through the wall of the gastrointestinal tract, it can cause perforation, which is a hole that allows gastric contents to leak into the peritoneal cavity. This can cause peritonitis, which is an inﬂammation and infection of the peritoneum. Peritonitis can cause severe upper abdominal pain, which may radiate to the shoulder or back. The pain may be sudden, sharp, and constant.

A. Obtain the client’s vital signs. B. Weigh the client. C. Administer pain medication. D. Change the client’s dressing.

Correct Answer is C

Explanation

Choice A: Obtain the client’s vital signs. This is an important nursing action, but not the priority. The nurse should monitor the client’s vital signs for signs of infection, ﬂuid imbalance, or shock, but these are not as urgent as relieving the client’s pain.

Choice B: Weigh the client. This is a necessary nursing action, but not the priority. The nurse should weigh the client daily to assess their ﬂuid status and nutritional needs, but this can be done after addressing the client’s pain.

Choice C: Administer pain medication. This is the priority nursing action because the nurse should follow the principle of Maslow’s hierarchy of needs and address the client’s physiological needs first. Pain can interfere with the client’s healing process and aﬀect their quality of life.

Choice D: Change the client’s dressing. This is a required nursing action, but not the priority. The nurse should change the client’s dressing to prevent infection and promote wound healing, but this can be done after administering pain medication to make the procedure more comfortable for the client.

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has peptic ulcer disease. Which of the following findings is a manifestation of gastrointestinal perforation?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

A nurse is assisting with the plan of care for a client who has hypothyroidism with myxedema. Which of the following interventions should the nurse include in the plan of care?

A nurse is collecting data from a client who has gastroesophageal reﬂux disease (GERD) and reports having heartburn every night. Which of the following actions should the nurse identify as a contributing factor to the client’s heartburn?

A nurse is collecting data from a client who has diabetes mellitus. Which of the following findings indicates that the client is experiencing DKA?

A nurse in a clinic is caring for a client who has a new diagnosis of hypothyroidism. Which of the following findings should the nurse expect?

A nurse is caring for a client who is postoperative and has a history of Addison’s disease. For which of the following manifestations should the nurse monitor?

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