The nurse has reviewed the Provider Prescriptions at 1045.
Which of the following actions should the nurse perform first?
Apply dressing to the foot wound.
Administer regular insulin 4 units subcutaneously x 1 dose.
schedule an appointment with an ophthalmologist.
Consult an outpatient wound care specialist.
The Correct Answer is B
Rationale for Correct Choice
- Administer regular insulin 4 units subcutaneously x 1 dose: The client’s blood glucose is significantly elevated at 250 mg/dL and they are showing signs of hyperglycemia (polyuria, weight loss, nausea). Administering insulin addresses an immediate metabolic imbalance and helps prevent complications such as diabetic ketoacidosis.
Rationale for Incorrect Choices
- Apply dressing to the foot wound: Although the wound requires care, it is not the most urgent issue. Delaying insulin administration in a hyperglycemic client with systemic symptoms could increase the risk of metabolic crisis. Wound care can follow stabilization.
- Schedule an appointment with an ophthalmologist: While ophthalmologic evaluation is essential for clients with diabetes, this is a non-urgent referral and can be scheduled after acute needs like hyperglycemia and wound care are addressed.
- Consult an outpatient wound care specialist: Coordinating specialized wound care is important for infection control and healing, but it is not time-sensitive. The priority is addressing the elevated blood glucose level first to stabilize the client's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Albumin 4.8 g/dL (3.5 g/dL to 5 g/dL): This albumin level is within the normal range and does not suggest a complication of cirrhosis. Cirrhosis often leads to low albumin levels, so a level of 4.8 g/dL is a positive finding and not indicative of a complication.
B. WBC count 8,000/mm3 (5,000 to 10,000/mm3): This white blood cell count is within the normal range and does not suggest a complication. An elevated WBC count may occur in cirrhosis if there is an infection, but this value is within the normal range.
C. Platelets 325,000/mm3 (150,000 to 400,000/mm3): This platelet count is also within the normal range. Cirrhosis typically causes a decrease in platelet count due to spleen enlargement (splenomegaly) or bone marrow suppression.
D. RBC count 4 million/mm3 (4.2 to 5.4 million/mm3): This red blood cell count is lower than the normal range, which could indicate anemia, a common complication of cirrhosis. Anemia in cirrhosis can result from various factors, including chronic bleeding (such as from varices), poor nutrition, or bone marrow suppression.
Correct Answer is A
Explanation
A. Speech-language pathologist: Speech-language pathologist specializes in assessing and treating swallowing difficulties, such as dysphagia, which is common after a stroke. The SLP will provide strategies for safe swallowing, conduct swallow studies, and recommend modifications to diet or feeding techniques to prevent aspiration.
B. Respiratory therapist: While a respiratory therapist may be needed if the client has respiratory issues or difficulty breathing, they are not typically the primary specialist for managing dysphagia.
C. Occupational therapist: An occupational therapist focuses on helping clients with activities of daily living (ADLs), such as dressing, grooming, and fine motor skills. While important for stroke recovery, they are not the primary specialist for dysphagia management.
D. Physical therapist: A physical therapist works with clients on improving mobility, strength, and balance. Though essential for stroke rehabilitation, physical therapy does not focus on the management of dysphagia.
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