A nurse manager is updating protocols for the use of belt restraints.

Which of the following guidelines should the nurse manager include?

The correct answer is choice C. A client who was just given a glass of orange juice for a low blood glucose level.

This client should be assessed first because they are at risk of hypoglycemia, which is a medical emergency that can cause seizures, coma, or death if not treated promptly.

The nurse should check the client’s blood glucose level again and provide additional carbohydrates or glucose if needed.

Choice A is wrong because a client who is scheduled for a procedure in 1 hr is not in immediate danger and can be assessed later.

The nurse should verify the client’s consent, allergies, and vital signs before the procedure, but this is not a priority over a client with low blood glucose.

Choice B is wrong because a client who received a pain medication 30 min ago for postoperative pain is likely to have improved pain relief and does not need immediate assessment.

The nurse should monitor the client’s pain level, vital signs, and respiratory status periodically, but this is not a priority over a client with low blood glucose.

Choice D is wrong because a client who has 100 mL of fluid remaining in his IV bag is not in immediate danger and can be assessed later.

The nurse should change the IV bag when it is empty or nearly empty, but this is not a priority over a client with low blood glucose.

Normal blood glucose levels are between 70 to 100 mg/dL (3.9 to 5.5 mmol/L) when fasting, and less than 140 mg/dL (7.8 mmol/L) two hours after eating. A blood glucose level below 70 mg/dL (3.9 mmol/L) is considered hypoglycemia and requires immediate treatment. Orange juice is a source of simple carbohydrates that can raise blood glucose quickly, but it may not be enough to prevent hypoglycemia in some cases.

The correct answer is choiced. A client who is taking warfarin and has an INR of 1.8.

Choice A rationale:

An induration after a Mantoux test indicates a positive reaction, but it does not necessarily require immediate follow-up unless the induration is significant and the client has risk factors for tuberculosis.

Choice B rationale:

Sodium phosphate is commonly used as a bowel preparation for colonoscopy. This does not typically require follow-up unless the client experiences adverse effects such as dehydration or electrolyte imbalance.

Choice C rationale:

A potassium level of 3.6 mEq/L is within the normal range (3.5-5.0 mEq/L). Therefore, this finding does not require follow-up.

Choice D rationale:

An INR of 1.8 for a client taking warfarin is below the therapeutic range for most indications (typically 2.0-3.0). This requires follow-up to adjust the warfarin dosage to achieve the desired anticoagulation effect.