At 8 a.m. the nurse is reviewing patient assignments and notes one of the patients has a current blood glucose of 264. Breakfast is routinely served at 8:30. The following orders are noted in the chart. What action should the nurse take? Accucheck before meals and at bedtime with sliding scale insulin aspart SQ: Glucose 0-150 Administer 0 units; 151-200 Administer 2 units; 201-250 Administer 4 units: 251-300 Administer 6 units: 301-350 Administer 8 units; 351- 400 Administer 10 units; >400 Notify physician.
Provide 2 units insulin aspart 50
Provide 6 units insulin aspart 50
Provide 10 units insin apart SQ
Provide 4 units insulin aspart 50
The Correct Answer is B
A. This option corresponds to the blood glucose range of 151-200. However, the patient's current blood glucose level is 264, which falls into the range of 251-300. Therefore, administering 2 units would not be appropriate in this case.
B. The patient's current blood glucose level is 264, which falls into the range of 251-300. According to the sliding scale insulin aspart orders, for this range, 6 units should be administered. This option aligns with the patient's blood glucose level and the prescribed protocol.
C. This option corresponds to the blood glucose range of 351-400. The patient's blood glucose level of 264 does not fall into this range, so administering 10 units would be excessive and potentially lead to hypoglycemia.
D. This option corresponds to the blood glucose range of 201-250. The patient's current blood glucose level is 264, which falls into the range of 251-300. Therefore, administering 4 units would not be sufficient to address the elevated blood glucose level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
One gram is equal to 1000 milligrams, and one teaspoon is equal to 5 milliliters. Therefore, the nurse can use the following formula:
0.4 g x 1000 mg/g x 5 mL/100 mg x 1 tsp/5 mL = 2 tsp
The nurse will instruct the client to take two teaspoons of cough syrup every four hours as prescribed by the primary health-care provider.
Correct Answer is D
Explanation
A. Incorrect. Withholding insulin during illness is not recommended. Clients with type 1 diabetes should continue to take their prescribed insulin even when they are ill. Insulin is necessary to regulate blood glucose levels, and illness can increase the body's demand for insulin.
B. Incorrect. Drinking calorie-free liquids is important to prevent dehydration during illness, but specific fluid amounts should be individualized based on the client's needs and healthcare provider's recommendations. The given volume is not a universally applicable guideline.
C. Incorrect. Testing blood glucose levels every 8 hours may not be frequent enough during illness. Blood glucose should be monitored more frequently to closely track changes in response to illness and adjust insulin doses accordingly.
D. Correct. Checking urine for ketones when blood glucose levels exceed 240 mg/dL is an important guideline during illness. Elevated blood glucose levels can lead to the production of ketones, and checking for ketones in the urine helps identify the early signs of diabetic ketoacidosis (DKA). If ketones are present, the client should follow a specific plan of action as outlined by their healthcare provider, which may include adjusting insulin doses or seeking medical attention.
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