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 A
Explanation
Choice A: Sedentary lifestyle. This is a risk factor for developing type 2 diabetes mellitus, which is a condition that occurs when the body becomes resistant to the action of insulin or does not produce enough insulin to maintain normal blood glucose levels. Insulin is a hormone that helps glucose enter the cells and be used for energy. A sedentary lifestyle can increase the risk of type 2 diabetes mellitus by reducing physical activity, which can improve insulin sensitivity and lower blood glucose levels.
Choice B: Triglyceride level of 100 mg/dL. This is not a risk factor for developing type 2 diabetes mellitus, but rather a normal value. Triglycerides are a type of fat that circulates in the blood and can be used for energy or stored in adipose tissue. A high triglyceride level can indicate an increased risk of cardiovascular disease, but it is not directly related to type 2 diabetes mellitus.
Choice C: Blood glucose of 98 mg/dL. This is not a risk factor for developing type 2 diabetes mellitus, but rather a normal value. Blood glucose is the amount of glucose in the blood, which can vary depending on food intake, physical activity, and hormonal regulation. A high blood glucose level can indicate type 2 diabetes mellitus, but it is not a cause of it.
Choice D: Recent viral infection. This is not a risk factor for developing type 2 diabetes mellitus, but rather a possible trigger for type 1 diabetes mellitus, which is a condition that occurs when the immune system destroys the beta cells of the pancreas that produce insulin. A viral infection can trigger an autoimmune response that attacks the beta cells and causes type 1 diabetes mellitus.
Correct Answer is D
Explanation
Choice A: Peri-umbilical area. This is not an area that the nurse should inspect to monitor for the presence of jaundice in a client who is African American and has cholecystitis. The peri-umbilical area is the area around the navel, which is part of the skin. The skin can show jaundice, but it may be difficult to detect in clients with dark skin tones.
Choice B: Nail beds. This is not an area that the nurse should inspect to monitor for the presence of jaundice in a client who is African American and has cholecystitis. The nail beds are part of the skin that can show jaundice, but they may also be affected by other factors such as anemia, cyanosis, or nail polish.
Choice C: Webbed areas of the fingers. This is not an area that the nurse should inspect to monitor for the presence of jaundice in a client who is African American and has cholecystitis. The webbed areas of the fingers are part of the skin that can show jaundice, but they may also be influenced by other factors such as temperature, circulation, or pressure.
Choice D: Hard palate. This is an area that the nurse should inspect to monitor for the presence of jaundice in a client who is African American and has cholecystitis, which is an inflammation of the gallbladder. Jaundice is a yellowish discoloration of the skin and mucous membranes due to elevated bilirubin levels in the blood. Bilirubin is a pigment that is produced from the breakdown of red blood cells and is normally excreted in bile. If the gallbladder or bile ducts are inflamed or obstructed, bile cannot flow into the duodenum and bilirubin accumulates in the blood and tissues. The hard palate is a part of the oral mucosa that can show jaundice, especially in clients with dark skin tones.
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