After a change-of-shift report, which client should the nurse assess first?
A 50-yr-old patient who uses exenatide (Byetta) and is complaining of acute abdominal pain
A 23-yr-old patient with type 1 diabetes who has a blood glucose of 40 mg/dL
A 40-yr-old patient who is pregnant and whose oral glucose tolerance test is 202 mg/dL
A 19-yr-old patient with type 1 diabetes who has a hemoglobin A1C of 12%
The Correct Answer is B
A blood glucose level of 40 mg/dL indicates severe hypoglycemia, which is a medical emergency requiring immediate attention. Hypoglycemia can lead to confusion, altered mental status, seizures, and loss of consciousness if not treated promptly. Therefore, it is crucial to assess and intervene quickly to raise the patient's blood glucose level to a safe range.
While the other clients mentioned also require attention and appropriate care, the severity and immediate risk associated with severe hypoglycemia make it the priority situation. The nurse should initiate appropriate treatment for hypoglycemia, such as administering glucose or glucagon, and closely monitor the patient's response.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Notify the surgeon that the informed consent process is not complete.The nurse should inform the surgeon because the surgeon is responsible for ensuring that the patient has adequate information and understands the procedure. It is not appropriate for the nurse to proceed with the consent process if the patient has questions or uncertainties.
B. Notify the operating room nurse to give a more complete explanation of the procedure.While the operating room nurse plays a role in the surgical process, it is the surgeon’s responsibility to provide a complete explanation of the procedure.
C. Provide a thorough explanation of the planned surgical procedure.While it’s important to provide information, the nurse is not authorized to explain the surgical procedure in detail. The surgeon should explain the surgery, as they have the training and knowledge to address all aspects of the procedure and answer any specific questions.
D. Give the prescribed preoperative antibiotics and withhold sedative medications.Administering preoperative medications, including antibiotics, without completed informed consent would be inappropriate. The patient must fully understand the procedure and consent to it before any medications are given.
Correct Answer is B
Explanation
According to the given information, Aydan's insulin lispro (Humalog) dosage is 1 unit per 50 grams of carbohydrates eaten. As Aydan has just consumed 150 grams of carbs for lunch, we can calculate the insulin dose as follows:
Insulin dose = Carbohydrates eaten / Insulin-to-carbohydrate ratio Insulin dose = 150 grams / 50 grams/unit
Insulin dose = 3 units
Therefore, the nurse should prepare to administer 3 units of Aydan's prescribed rapid-acting insulin (Insulin lispro) to cover the carbohydrates he consumed for lunch. The long-acting insulin (Glargine) is typically given at bedtime to provide a basal insulin level and is not directly related to meal coverage.
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