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 ["B","C","D","E"]
Explanation
The initial bundle of care in sepsis includes the following:
- Obtain blood cultures: Blood cultures help identify the specific microorganism causing the infection, which is important for guiding appropriate antibiotic therapy.
- Administer broad-spectrum antibiotics: Early administration of antibiotics is crucial in sepsis to target the suspected or likely infectious organisms. Broad-spectrum antibiotics cover a wide range of potential pathogens until more specific information from culture results is available.
- Obtain lactate levels: Measuring lactate levels helps assess tissue perfusion and can be used as an indicator of the severity of sepsis. Elevated lactate levels are associated with tissue hypoperfusion and increased mortality.
- Administer IV fluid bolus: Early aggressive fluid resuscitation is an essential component of sepsis management. Administering intravenous fluids helps restore intravascular volume and improve tissue perfusion.
- Administration of vasopressors: Especially in the setting of hypotension and to maintain MAP above 65mmHg.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.