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
Explanation
Prednisone is a corticosteroid medication that can cause a range of side effects, including fluid retention, electrolyte imbalance, and increased blood pressure. A blood pressure reading of 148/94 mm Hg indicates hypertension, which may be related to the use of prednisone. It is essential to report this finding to the health care provider as it may require further evaluation and management, such as adjusting the medication dosage or initiating additional treatments to control blood pressure. The other information provided, such as stopping the medication, ankle edema, and not taking prescribed vitamin D, is relevant but does not pose an immediate threat to the patient's health compared to uncontrolled hypertension.
Correct Answer is C
Explanation
Pneumonia is an infection that causes inflammation in the lungs. Auscultation refers to listening to the sounds produced by the lungs using a stethoscope. Ronchi and fine crackles are abnormal lung sounds that can be heard during auscultation in individuals with pneumonia.
These sounds are associated with the presence of fluid or mucus in the lungs, which is characteristic of pneumonia.
While other symptoms such as a sore throat, tympany noted on chest percussion, and a slightly elevated temperature (37.8 degrees Celsius) can be present in various respiratory conditions, the auscultation findings of ronchi or fine crackles specifically suggest an underlying lung infection like pneumonia.
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