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 A

Explanation

Choice A reason: An elevated serum rheumatoid factor is most commonly associated with rheumatoid arthritis, an autoimmune disease. This finding supports the diagnosis and indicates the presence of autoantibodies that attack the body's own tissues. The rheumatoid factor is used as one of the diagnostic criteria for rheumatoid arthritis and confirms the autoimmune nature of the disease. It does not indicate disease severity or progression but rather the presence of the disease.

Choice B reason: An elevated serum rheumatoid factor is not necessarily representative of a decline in the client's condition. While high levels of rheumatoid factor can be present in individuals with active disease, they do not directly correlate with disease activity or progression. The presence of rheumatoid factor alone does not provide information about the current state or severity of the client's condition.

Choice C reason: An elevated serum rheumatoid factor does not indicate the onset of joint degeneration. Rheumatoid factor is an antibody that indicates the presence of an autoimmune response but does not directly cause joint damage. Joint degeneration in rheumatoid arthritis results from the chronic inflammation and immune response within the joints, leading to tissue damage over time. Rheumatoid factor is a marker of the disease but not a direct indicator of joint damage.

Choice D reason: An elevated serum rheumatoid factor is not evidence of the spread of the disease to the kidneys. Rheumatoid arthritis primarily affects the joints and can also have systemic manifestations, but the presence of rheumatoid factor is not indicative of kidney involvement. Kidney involvement in rheumatoid arthritis is relatively rare and would typically require additional diagnostic tests and clinical evaluation to determine.

A. Take and monitor vital signs. B. Administer additional nebulizer treatment. C. Increase oxygen flow rate. D. Raise the head of the bed. E. Provide client with a spirometer for use.

Correct Answer is ["B","C","D"]

Explanation

Choice A reason: Monitoring vital signs is crucial to assess the client's current condition and detect any further deterioration. Changes in vital signs can indicate the effectiveness of the treatment and whether additional interventions are needed. For instance, if the heart rate continues to rise or oxygen saturation drops further, it suggests that the client's condition is worsening and requires immediate attention. Keeping a close eye on the vital signs helps the healthcare team to make timely decisions and adjust the treatment plan as necessary.

Choice B reason: Administering additional nebulizer treatment is necessary because the client is still experiencing shortness of breath and bilateral wheezes even after the initial medication. Nebulizer treatments, such as those containing albuterol and ipratropium, help to relax and open the airways, making breathing easier. Given the client's severe asthma symptoms and the fact that the previous doses were not completely effective, additional treatment can provide the needed relief and prevent further respiratory distress.

Choice C reason: Increasing the oxygen flow rate is essential to improve the client's oxygen saturation levels. The current oxygen saturation of 91% indicates hypoxemia, which can lead to severe complications if not addressed promptly. By increasing the flow rate, the client can receive a higher concentration of oxygen, helping to maintain adequate oxygenation of tissues and organs. Continuous monitoring of oxygen saturation is also important to ensure that the increased flow rate is effective and to make further adjustments if needed.

Choice D reason: Raising the head of the bed helps to facilitate easier breathing for the client. This position allows gravity to assist in the expansion of the lungs and reduces the pressure on the diaphragm, making it easier for the client to take deeper breaths. It also helps to reduce the work of breathing and can be particularly beneficial for clients experiencing respiratory distress. Ensuring that the client is in a comfortable and optimal position for breathing is an important aspect of asthma management.

Choice E reason: While providing a spirometer can be useful for lung function exercises, it is not the immediate priority in this acute situation. The client's primary concern is to stabilize their breathing and ensure adequate oxygenation. Once the client is stable, a spirometer can be introduced as part of long-term management and rehabilitation to improve lung function and monitor progress.

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Naxlex Comprehensive Predictor Exams

A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?

Correct Answer is A

Explanation

Exhibits After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

A client receiving thrombolytic infusions for treatment of an acute myocardial infarction (AMI) has which nursing problem?

A client who is experiencing a first gouty arthritis attack reports excruciating pain in the right great toe. The nurse inspects the inflamed joint and administers ibuprofen 800mg PO as prescribed. Which instruction should the nurse include in the discharge teaching?

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?

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.

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?

Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first?

An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rales and wheezing. When assessing this client, which additional finding is the nurse likely to obtain?