The nurse has reviewed the provider prescriptions at 1045.
Which of the following actions should the nurse perform first?
Apply dressing to foot wound.
Consult outpatient wound care specialist.
Schedule appointment with ophthalmologist.
Administer regular insulin 4 units subcutaneously x 1 dose
None
None
The Correct Answer is D
Apply dressing to foot wound: While wound care is important, managing hyperglycemia takes priority. High blood glucose impairs wound healing and increases infection risk, making insulin administration the more urgent intervention. Dressing application should follow glycemic control measures.
Consult outpatient wound care specialist: A wound care consultation is appropriate for managing a chronic ulcer, but immediate intervention is required to stabilize glucose levels. Optimizing wound care should come after initial glucose management.
Schedule appointment with ophthalmologist: Clients with diabetes require routine eye exams due to the risk of diabetic retinopathy. However, addressing hyperglycemia and preventing further infection are more urgent concerns at this time.
Administer regular insulin 4 units subcutaneously x 1 dose: The client's blood glucose is elevated (250 mg/dL), which can impair immune function and tissue healing. Lowering glucose with insulin is the priority to prevent complications such as worsening infection or ketoacidosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Initiate oxygen therapy: Sepsis can lead to tissue hypoxia and organ dysfunction due to impaired perfusion. Oxygen therapy is the priority to ensure adequate oxygenation, prevent respiratory failure, and support vital organ function.
B. Administer antibiotics: Broad-spectrum antibiotics are essential to treat the underlying infection, but they should be given after obtaining blood cultures to ensure accurate pathogen identification and prevent delays in appropriate therapy.
C. Obtain blood cultures: Blood cultures must be collected before antibiotic administration to identify the causative organism, but stabilizing the client's oxygenation and perfusion takes precedence in acute management.
D. Begin an IV crystalloid infusion: Fluid resuscitation is crucial for managing septic shock, but oxygen therapy should be initiated first to immediately improve oxygen delivery and prevent hypoxia-related complications.
Correct Answer is D
Explanation
A. Temperature of 38° C (100.4° F): An elevated temperature may indicate infection, which is a potential complication of TPN due to the risk of central line-associated bloodstream infections. However, fever is not a sign of fluid volume overload.
B. Urinary output of 20 mL in the past hour: Oliguria (low urine output) is more commonly associated with dehydration or renal impairment rather than fluid volume overload. In fluid overload, urine output may initially increase if kidney function is normal.
C. +1 pedal pulses: Weak pulses can indicate poor circulation, hypovolemia, or peripheral vascular disease. In fluid overload, bounding pulses rather than weak pulses are typically observed due to increased intravascular volume.
D. S3 heart sound: An S3 heart sound (ventricular gallop) occurs when excess fluid volume causes rapid ventricular filling, leading to abnormal heart sounds. This finding is a classic sign of fluid volume overload and can indicate heart failure or significant fluid retention.
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