The nurse is preparing a 50 mL dose of 50% dextrose IV for a patient with insulin shock. What is the appropriate method for administering the medication?

Mix the dextrose in a 50 mL piggyback for a total volume of 100 mL.

Dilute the dextrose in one liter of 0.9% normal saline solution.

Request the pharmacist to add the dextrose to a total parenteral nutrition (TPN) solution.

Administer the undiluted dextrose slowly through the currently infusing IV. .

Answer and Explanation

The Correct Answer is D

Choice A rationale
Mixing the dextrose in a 50 mL piggyback for a total volume of 100 mL is not the appropriate method for administering the medication. This would dilute the dextrose, reducing its concentration and potentially making it less effective.
Choice B rationale
Diluting the dextrose in one liter of 0.9% normal saline solution is not the appropriate method for administering the medication. This would significantly dilute the dextrose, reducing its concentration and potentially making it less effective.
Choice C rationale
Requesting the pharmacist to add the dextrose to a total parenteral nutrition (TPN) solution is not the appropriate method for administering the medication. While dextrose is often a component of TPN solutions, in this case, the patient requires a concentrated dose of dextrose to treat insulin shock.

Choice D rationale
This is the correct answer. Administering the undiluted dextrose slowly through the currently infusing IV is the appropriate method for administering the medication. This allows for the rapid administration of a concentrated dose of glucose, which is necessary to quickly raise the patient’s blood glucose level in the case of insulin shock.

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Correct Answer is A

Explanation

Choice A rationale

Heparin is an anticoagulant medication that prevents the formation of blood clots. One of the most common and serious side effects of heparin therapy is bleeding. Therefore, it is crucial for the nurse to observe for signs of bleeding, such as bruising, petechiae, hematomas, black tarry stools, hematuria, and changes in mental status. Regular laboratory monitoring of the client’s coagulation status, specifically the activated partial thromboplastin time (aPTT), is also necessary to ensure therapeutic levels of heparin without causing excessive bleeding.

Choice B rationale

While mobilization can help prevent the formation of new clots, it is not the most important intervention for a client who is already on a heparin protocol for DVT. Mobilization can potentially dislodge the existing clot, leading to a life-threatening pulmonary embolism.

Choice C rationale

Although it is important to monitor vital signs in all clients, assessing blood pressure and heart rate every 4 hours is not the most important intervention for a client on a heparin protocol.

Changes in blood pressure and heart rate are not specific to heparin therapy and do not provide direct information about the effectiveness or side effects of the medication.

Choice D rationale

Measuring each calf’s girth can help evaluate the progression of edema in the affected leg, but it is not the most important intervention for a client on a heparin protocol. While it can provide information about the local effects of the DVT, it does not address the systemic anticoagulation effects of heparin therapy.

A. Test the fluid on the dressing for glucose. B. Change the dressing using a compression bandage. C. Mark the drainage area with a pen and continue to monitor. D. Document the findings in the electronic medical record.

Correct Answer is A

Explanation

Choice A rationale
Testing the fluid on the dressing for glucose is the immediate course of action when a nurse notices clear fluid on the surgical dressing of a patient who has just returned from lumbar spinal surgery. Clear fluid could be cerebrospinal fluid (CSF), which contains glucose. If the fluid is positive for glucose, it could indicate a CSF leak, which requires immediate medical attention.
Choice B rationale
Changing the dressing using a compression bandage is not the immediate course of action. The source of the fluid needs to be identified first.
Choice C rationale
Marking the drainage area with a pen and continuing to monitor is not the immediate course of action. The source of the fluid needs to be identified first.
Choice D rationale
Documenting the findings in the electronic medical record is important, but it is not the immediate course of action. The source of the fluid needs to be identified first.

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The nurse is preparing a 50 mL dose of 50% dextrose IV for a patient with insulin shock. What is the appropriate method for administering the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client’s plan of care?

Correct Answer is A

Explanation

A nurse notices clear fluid on the surgical dressing of a patient who has just returned from lumbar spinal surgery. What should be the nurse’s immediate course of action?

Correct Answer is A

Explanation

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