The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which is the best initial nursing action?

Choice A reason: Preparing the prescribed dose of rapid-acting insulin from the sliding scale instructions is not appropriate when the client's blood glucose level is low (56 mg/dL). Administering insulin at this point could further lower the blood glucose level, potentially leading to severe hypoglycemia. The priority is to raise the client's blood glucose level to a safe range.

Choice B reason: Giving the client six ounces of non-diet carbonated soda and instructing the client to drink it entirely is the correct first intervention. The client’s blood glucose level is significantly below the normal reference range (hypoglycemia). Administering a fast-acting carbohydrate, such as non-diet soda, helps to quickly increase the blood glucose level to a safer range. This intervention addresses the immediate need to correct the hypoglycemia and prevent potential complications such as confusion, seizures, or loss of consciousness.

Choice C reason: Collecting a blood specimen by venipuncture to send to the laboratory for serum glucose analysis is not the first intervention to implement. While laboratory confirmation of blood glucose levels can be important, the immediate priority is to treat the hypoglycemia. Delaying treatment to collect a laboratory specimen could result in worsening of the client's condition. Immediate administration of a fast-acting carbohydrate should be prioritized.

Choice D reason: Documenting the glucose reading in the electronic medical record (EMR) is important but not the first priority. While accurate documentation is necessary for ongoing care, the immediate intervention should focus on treating the hypoglycemia. Once the client's blood glucose level has been stabilized, the nurse can then document the reading and subsequent interventions in the EMR.

Choice A reason: Eliminating whole milk and dairy servings of ice cream is an appropriate choice for a client with cholecystitis. These foods are high in fat, and a low-fat diet is recommended for managing cholecystitis. High-fat foods can stimulate the gallbladder to contract, which can exacerbate symptoms and cause pain. By removing these high-fat items from their diet, the client is following the recommended dietary guidelines for managing cholecystitis.

Choice B reason: Eliminating citrus fruit and melon with a salt substitute does not specifically address the dietary recommendations for cholecystitis. While citrus fruits and melon are generally healthy choices, they are not high in fat and do not need to be eliminated from the diet. Additionally, using a salt substitute does not have a significant impact on cholecystitis management.

Choice C reason: Eliminating pasta with herbal butter and no meat sauce is not necessary for managing cholecystitis. Pasta itself is not high in fat, and using herbal butter instead of regular butter can be a lower-fat option. As long as the pasta dish is prepared with low-fat ingredients, it can be part of a cholecystitis-friendly diet.

Choice D reason: Eliminating canned vegetables with additional table salt does not specifically address the dietary recommendations for cholecystitis. While it is generally a good idea to limit sodium intake for overall health, this recommendation is more relevant for managing conditions like hypertension. The focus for cholecystitis management should be on reducing dietary fat rather than sodium.