Breakfast trays have arrived on the unit, but the daily serum glucose level is not available on the chart of a client with type 1 diabetes mellitus. Which action should the nurse take?

Verify with client that the blood was drawn.

Check when insulin was last administered.

Perform a capillary glucose test.

Give the client the breakfast tray.

Answer and Explanation

The Correct Answer is C

Choice A rationale: Verifying with the client that the blood was drawn is a good practice, but it might not provide immediate information about the current glucose level. The nurse needs a timely assessment to determine whether the client can safely receive the scheduled breakfast.

Choice B rationale: Checking when insulin was last administered is important, but it doesn't provide real-time information about the current glucose level. The nurse needs this information before deciding on breakfast administration.

Choice C rationale: Performing a capillary glucose test is a quick way to obtain current blood glucose levels, allowing the nurse to make an informed decision about administering the breakfast tray. This action is consistent with assessing the client's immediate status.

Choice D rationale: Giving the client the breakfast tray without knowing the current glucose level could be unsafe and against the prescribed plan of care. Assessing the glucose level is a necessary step before administering meals, especially in clients with diabetes.

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Correct Answer is B

Explanation

Choice A rationale: While the client with the gunshot wound requires attention, the client with a collapsed left lower lung and 100 ml drainage in a chest tube collection container is at immediate risk for respiratory compromise.

Choice B rationale: The client who fell from a ladder with a collapsed left lower lung and 100 ml drainage in a chest tube collection container requires the most immediate intervention to address potential respiratory distress.

Choice C rationale: The client post-mastectomy with 50 ml of serosanguineous fluid in a Jackson-Pratt drain may need attention, but the respiratory distress in the other client takes precedence.

Choice D rationale: The client who had an abdominal perineal resection with no drainage on the dressing and reporting chills may require attention, but the respiratory distress in the other client is a more urgent concern.

A. Instruct unlicensed assisted personnel (UPS) to transfer all non-ambulatory clients via wheelchairs. B. Announce in a calm voice that all visitors should proceed immediately to the first floor via the service elevators. C. Shut all doors to client rooms and tell everyone to stay in their rooms until the fire department arrives. D. Instruct the nursing staff to evacuate ambulatory clients to the nearest fire exits.

Correct Answer is D

Explanation

Choice A rationale: Instructing unlicensed assisted personnel to transfer non-ambulatory clients via wheelchairs may delay the evacuation process and put clients at risk. Choice B rationale: Announcing that visitors should proceed immediately to the first floor via the service elevators may cause congestion and hinder the evacuation of clients.

Choice C rationale: Shutting all doors to client rooms and telling everyone to stay in their rooms is not a safe strategy during a fire evacuation. It may increase the risk of harm to clients and staff.

Choice D rationale: Instructing the nursing staff to evacuate ambulatory clients to the nearest fire exits is the most appropriate and timely action to ensure the safety of both clients and staff during a fire evacuation.

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Breakfast trays have arrived on the unit, but the daily serum glucose level is not available on the chart of a client with type 1 diabetes mellitus. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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