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 A
Explanation
A. Correct. Chvostek's sign is a clinical sign of hypocalcemia. It is elicited by tapping on the facial nerve, just anterior to the ear, and observing for facial twitching or spasm.
B. Incorrect. Kernig's sign is a test for assessing meningitis and involves flexing the hip and knee at 90-degree angles and then extending the knee. This test is not relevant to the client's reported symptoms.
C. Incorrect. Brudzinski's sign is another test for assessing meningitis. It involves flexing the neck forward and observing for involuntary flexion of the hips and knees. This test is not relevant to the client's reported symptoms.
D. Incorrect. Babinski's sign is used to assess upper motor neuron lesions. It involves stimulating the sole of the foot, and in a positive response, the big toe extends upward. This test is not relevant to the client's reported symptoms.
Correct Answer is D
Explanation
- Choice A Rationale: Placing the head of the bed in the flat position is not recommended as it can increase the risk of airway obstruction and reduce venous drainage from the head, which is especially critical after thyroid surgery.
- Choice B Rationale: While deep breathing is important postoperatively, it is not specific to thyroidectomy care and should be done more frequently than every 4 hours to ensure adequate ventilation and prevent atelectasis.
- Choice C Rationale: Hyperextending the client's neck can be harmful post-thyroidectomy as it may put stress on the surgical site, potentially leading to dehiscence or damage to the area.
- Choice D Rationale: Checking the client's voice every 2 hours is essential after a thyroidectomy because vocal cord paralysis can be an indicator of recurrent laryngeal nerve damage, which is a potential complication of the surgery. Monitoring the voice allows for early detection and intervention.
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