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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Keeping alarm levels low is important to reduce stress and promote a healing environment, but it is not the most impactful intervention for personalized care.

Choice B reason: Dimming the lights at night helps maintain a normal sleep-wake cycle, which is beneficial but not as specific to the client's individual needs as continuity of care.

Choice C reason: Having the same nurses care for the patient on consecutive days can provide consistency and build trust, which is especially important for a child in critical condition.

Choice D reason: While visits from school friends can be uplifting, they may not be feasible or appropriate for a client in critical condition in the PICU. The priority is ensuring stable and consistent care.

A. Had an upper respiratory infection with a sore throat about 3 weeks ago. B. Suffered chest trauma with a fractured rib after a bicycle accident 2 weeks ago. C. The child was born with a heart defect that was repaired at 6 months of age. D. Has had a decreasing appetite over the course of several months.

Correct Answer is A

Explanation

Choice A reason: This is the correct choice. Rheumatic fever is often preceded by an upper respiratory infection caused by group A Streptococcus, which can lead to a sore throat.
Choice B reason: Chest trauma and a fractured rib are not related to the development of rheumatic fever.
Choice C reason: Although a pre-existing heart defect can increase the risk of complications, it is not the cause of rheumatic fever.
Choice D reason: A decreasing appetite over several months is not specifically indicative of rheumatic fever.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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