The nurse is assessing a client with peptic ulcer disease (PUD). Which finding, if observed by the nurse, would require immediate follow-up?

Choice A rationale

Glucagon IM is inappropriate for a glucose of 85 mg/dL, which is within normal preprandial ranges of 70-100 mg/dL. It is reserved for severe hypoglycemia with symptoms like unconsciousness.

Choice B rationale

Calling the MD is unnecessary when blood glucose is in the normal range and the patient is symptomatic. Nutritional intake is the next logical step in management.

Choice C rationale

Holding insulin and allowing the patient to eat is appropriate for 85 mg/dL. Nutritional intake stabilizes glucose levels, maintaining euglycemia without risking hypoglycemia from insulin.

Choice D rationale

Administering 10 units of Humalog risks causing hypoglycemia, as this dose is excessive for a glucose level of 85 mg/dL. Insulin use is not indicated here.

Choice E rationale

Administering dextrose IVP unnecessarily increases glucose levels. It is inappropriate unless the patient is symptomatic and glucose levels drop below 70 mg/dL.

Choice F rationale

Administering 7 units of Humalog risks hypoglycemia for a glucose level of 85 mg/dL, as the dose is excessive and unnecessary without elevated glucose.

Choice G rationale

Administering 5 units of Humalog poses a risk for hypoglycemia and is not indicated with normal glucose levels. Nutritional intake alone suffices.

Choice H rationale

Administering 15 units of Humalog is inappropriate and dangerous for a normal glucose level, as it likely induces hypoglycemia. Insulin use should be avoided here. .

Choice A rationale

Blood pressure of 85/55 indicates hypotension, which can compromise perfusion to vital organs such as the brain and kidneys. Immediate assessment is necessary to determine the underlying cause, such as dehydration or internal bleeding.

Choice B rationale

Hemoglobin level of 7 g/dL is critically low, falling below the normal range of 12–16 g/dL for women or 13–18 g/dL for men. This reflects severe anemia, which may require urgent intervention, including blood transfusion or addressing the cause of anemia.

Choice C rationale

Massive bleeding from the right lower leg is an emergency due to the risk of hypovolemic shock and significant blood loss. Stabilization of the bleeding site and monitoring for signs of systemic impact is required immediately.

Choice D rationale

A temperature of 96.5°F (35.8°C) may signal mild hypothermia or a systemic condition. While it requires follow-up, it is not as immediately life-threatening as the other findings and therefore does not warrant immediate prioritization.