The nurse obtains a fingerstick blood glucose level using a bedside glucose meter from a client with a prescribed sliding scale insulin protocol. The meter indicates 56 mg/dL (3.12 mmol/L). At this time, which intervention should the nurse implement first?
Reference Range: Glucose 74 to 106 mg/dL (4.1 to 5.9 mmol/L)

Prepare the prescribed dose of rapid-acting insulin from the sliding scale instructions.

Give the client six ounces of non-diet carbonated soda and instruct the client to drink it entirely.

Collect a blood specimen by venipuncture to send to the laboratory for serum glucose analysis.

Document the glucose reading in the electronic medical record (EMR).

Answer and Explanation

The Correct Answer is B

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.

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Correct Answer is B

Explanation

Choice A reason: Polyuria and excessive thirst are classic symptoms of diabetes insipidus and indicate the body's inability to retain water due to a lack of antidiuretic hormone (ADH). While these symptoms need to be managed, they are not immediately life-threatening compared to severe hypernatremia.

Choice B reason: A serum sodium level of 185 mEq/L (185 mmol/L) indicates severe hypernatremia, which is an immediate medical emergency. Severe hypernatremia can lead to neurological symptoms such as confusion, seizures, and even coma due to the osmotic shift of water out of brain cells. Immediate intervention is required to correct the sodium imbalance and prevent serious complications.

Choice C reason: An apical heart rate of 110 beats per minute is indicative of tachycardia, which can be associated with dehydration and the body's response to maintain cardiac output. While it is a concern, it does not take precedence over the need to address severe hypernatremia.

Choice D reason: Dry skin with inelastic turgor is a sign of dehydration, which is a common issue in diabetes insipidus due to excessive fluid loss. While this requires attention, it is not as immediately critical as addressing severe hypernatremia, which poses a direct and urgent threat to the client's neurological and overall health.

A. Distinguish the difference between herpes varicella and herpes zoster. B. Explain that the risk of developing shingles decreases with age. C. Affirm that a person with shingles has a history of chickenpox infection. D. Ask the client to describe the type of shingles that her brother has. E. Instruct client to report the development of fatigue and low-grade fever.

Correct Answer is ["A","C","E"]

Explanation

Choice A reason: Distinguishing the difference between herpes varicella and herpes zoster is important for client education. Herpes varicella (chickenpox) and herpes zoster (shingles) are caused by the same virus, the varicella-zoster virus (VZV). After a person recovers from chickenpox, the virus remains dormant in the nerve tissues and can reactivate years later as shingles. Educating the client about the relationship between these two conditions helps in understanding the risk and nature of shingles.

Choice B reason: Explaining that the risk of developing shingles decreases with age is incorrect. In fact, the risk of developing shingles increases with age, especially in individuals over 50. The immune system's ability to keep the varicella-zoster virus dormant decreases with age, leading to a higher likelihood of reactivation as shingles. Therefore, this choice is not appropriate for client education.

Choice C reason: Affirming that a person with shingles has a history of chickenpox infection is accurate. Shingles occurs when the dormant varicella-zoster virus reactivates in someone who has previously had chickenpox. This information helps the client understand the connection between past chickenpox infection and the potential for developing shingles.

Choice D reason: Asking the client to describe the type of shingles that her brother has is not relevant to the client's own risk or education about shingles. The focus should be on providing accurate information about shingles and its relation to chickenpox, not on the details of another person's condition.

Choice E reason: Instructing the client to report the development of fatigue and low-grade fever is important because these can be early symptoms of shingles. Early identification and treatment of shingles can help manage symptoms and reduce complications. Educating the client on what to watch for and when to seek medical attention is crucial for effective management.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with diabetes insipidus (DI). Which data warrants the most immediate intervention by the nurse?Reference Range: Sodium 136 to 145 mEq/L (136 to 145 mmol/L)

Correct Answer is B

Explanation

A client reports to the nurse of recently visiting someone who has a shingles infection. The client believes that having had chickenpox as a child will be protective against shingles. How should the nurse respond? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

The nurse is assessing a client who is one day postoperative parathyroidectomy and finds that the client is experiencing stridor. After notifying the healthcare provider (HCP), the nurse should prepare for which procedure?

A client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about dietary restrictions. In discussing fluid intake, the nurse should include which type of fluid limitation?

A client who had a C5 spinal cord injury 2 years ago is admitted to the emergency department (ED) with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?