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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

Choice A reason: The client can now speak in full sentences without pausing, which indicates that the interventions were successful. This improvement suggests that the client's airways are less obstructed and he is able to breathe more easily. The ability to speak in full sentences is a key indicator of improved respiratory function and is often used as a measure of asthma control.

Choice B reason: Respirations at 16 breaths per minute indicate a successful intervention. This is within the normal range for adults and suggests that the client's breathing has stabilized. Before the intervention, the client’s respiratory rate was 28 breaths per minute, which is elevated and indicative of respiratory distress.

Choice C reason: Blood pressure at 122/84 mmHg does not indicate the success of the interventions. Blood pressure can be influenced by many factors and may not directly correlate with respiratory improvements. While the patient's blood pressure has decreased slightly, this change is not a definitive indicator of successful asthma treatment.

Choice D reason: The client reporting, "It’s a lot easier to breathe now," indicates successful interventions. This subjective report aligns with the clinical improvements observed in the client’s breathing and overall respiratory function. The client's perception of relief is an important aspect of assessing treatment efficacy.

Choice E reason: Heart rate at 105 beats per minute does not indicate the success of the interventions. Although the heart rate has decreased from 116 to 105 beats per minute, it is still elevated and may not directly reflect the improvement in respiratory status. Elevated heart rate could be due to anxiety or other factors unrelated to asthma management.

Choice F reason: Lung sounds being clear indicates successful interventions. Clear lung sounds suggest that the bronchospasm and airway obstruction have been relieved, which is a positive outcome of the administered medications and oxygen therapy. This objective finding is a strong indicator of improved respiratory function.

A. Administer PRN pain medication. B. Observe the leg for swelling. C. Assess peripheral pulses. D. Auscultate blood pressure.

Correct Answer is C

Explanation

Choice A reason: Administering PRN pain medication can help manage the client's discomfort, but it does not address the underlying cause of the pain. It is essential to assess and identify the source of the pain before administering pain relief. Providing pain medication without a thorough assessment may mask symptoms of a serious underlying issue.

Choice B reason: Observing the leg for swelling is important, as swelling can indicate complications such as compartment syndrome or infection. However, it is not the first action the nurse should take. While swelling is a significant sign, assessing blood flow to the extremity is more critical and should be prioritized.

Choice C reason: Assessing peripheral pulses is the correct first intervention. The presence of foot pain in a client with an external fixation device for a fractured femur could indicate compromised blood flow to the lower extremity. Assessing the peripheral pulses will help determine if there is adequate circulation. If pulses are weak or absent, it may suggest a serious vascular issue that requires immediate intervention to prevent further complications such as tissue ischemia or necrosis.

Choice D reason: Auscultating blood pressure is a routine assessment but does not directly address the immediate concern of left foot pain in this scenario. Blood pressure assessment is important for overall health monitoring but is not the priority when dealing with a possible vascular complication in the affected limb. Ensuring adequate blood flow to the extremity takes precedence.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The nurse has implemented additional needed actions. Indicate the assessment data which indicate the interventions were successful and which assessment data provide no indication that the interventions were successful. Each column must have at least one answer selected.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

A client with an external fixation device for a fractured left femur is troubled with left foot pain. Which intervention should the nurse implement first?

Correct Answer is C

Explanation

A client receives a prescription for 2 liters of lactated Ringer's IV to be infused over 12 hours. The IV administration set delivers 20 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

A nurse is caring for a client with acute kidney injury (AKI). Which assessment finding warrants immediate intervention?

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?

While completing a health assessment for a young adult female with acute appendicitis, the client informs the nurse that there is a chance that she may be pregnant. The operating team is preparing to take the client to surgery. Which intervention should the nurse implement immediately?

After teaching a client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Which food choices eliminated by the client indicate to the nurse that teaching has been successful?

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?

A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client’s plan of care?

When teaching a client with Parkinson's disease, which rationale for the prescription of carbidopa-levodopa should the nurse include?