The nurse obtains a fingerstick blood glucose level using bedside lancet/glucose meter equipment 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?
Give the client six ounces of non-diet carbonated soda and instruct the client to drink it entirely.
Document the glucose reading in the electronic medical record as the only action needed.
Collect a blood specimen by venipuncture to send to the laboratory for serum glucose analysis.
Prepare the prescribed dose of rapid-acting insulin from the sliding scale instructions.
The Correct Answer is A
Choice A reason: This is the correct choice. A blood glucose level of 56 mg/dL indicates hypoglycemia, and the immediate priority is to raise the blood sugar level. Non-diet carbonated soda can provide a quick source of sugar.
Choice B reason: Documenting the reading is important but does not address the immediate need to correct the low blood sugar.
Choice C reason: While confirming the reading with a laboratory test is a good practice, it is not the first action to take when dealing with hypoglycemia.
Choice D reason: Administering insulin would be contraindicated as it would lower the blood sugar even further.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: School-age children, typically around the ages of 6 to 12, begin to grasp the finality and irreversibility of death. They understand that death is universal and affects all living things.
Choice B reason: Preschool-age children may have some concept of death, but they often view it as reversible or temporary, not fully understanding its permanence.
Choice C reason: Toddlers are too young to comprehend the concept of death, as their cognitive development at this stage does not allow for such abstract thinking.
Choice D reason: While adolescents certainly understand the permanence of death, this awareness develops earlier, during the school-age years. Adolescents may begin to explore more complex philosophical and existential questions about life and death.
Correct Answer is D
Explanation
Choice A reason: Administering a bolus of D10W is not the first-line treatment for severe dehydration and may not address the immediate fluid needs of the infant.
Choice B reason: Offering an oral rehydration solution is not appropriate for an infant with severe dehydration and a compromised ability to hold down fluids.
Choice C reason: Administering a bolus of hypertonic saline is not typically the initial treatment for dehydration and could potentially worsen the infant's condition.
Choice D reason: This is the correct choice. Administering a bolus of normal saline is the immediate action to treat severe dehydration and restore circulatory volume.
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