The practical nurse (PN) reports to the charge nurse that a client who is receiving a parenteral nutrition infusion has a capillary glucose of 365 mg/dL (20.3 mmol/L). Which action should the charge nurse implement?

Determine if the client has a sliding scale insulin prescription.

Stop the infusion until the healthcare provider is notified.

Assess the client's urinary output for the previous 24 hours.

Review the client's record for a history of diabetes mellitus.

Answer and Explanation

The Correct Answer is A

Choice A reason: Determining if the client has a sliding scale insulin prescription is crucial. A sliding scale insulin regimen can help manage elevated blood glucose levels effectively. In the case of a capillary glucose of 365 mg/dL, prompt intervention is needed to prevent hyperglycaemia-related complications, and insulin administration is the most appropriate immediate action.

Choice B reason: Stopping the infusion until the healthcare provider is notified may not be the best immediate action. While it is essential to address the hyperglycaemia, halting the parenteral nutrition infusion can affect the client's overall nutritional and fluid balance. The focus should be on managing the glucose levels promptly.

Choice C reason: Assessing the client's urinary output for the previous 24 hours is important for monitoring overall fluid status and kidney function, but it does not directly address the immediate need to manage the elevated glucose levels.

Choice D reason: Reviewing the client's record for a history of diabetes mellitus can provide valuable information for long-term management and understanding the client's baseline glucose control. However, it is not the most urgent action in response to an acutely elevated capillary glucose level. Immediate intervention with insulin is needed to address the hyperglycaemia.

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Correct Answer is D

Explanation

Choice A reason: Minimizing the intake of spicy foods can help reduce GERD symptoms, but it is not the most critical instruction for preventing reflux immediately after eating.

Choice B reason: Beginning a smoking cessation program is important for overall health and can help reduce GERD symptoms over time, but it is not the immediate priority for preventing reflux.

Choice C reason: Avoiding tight-fitting clothes can help reduce pressure on the abdomen and lessen reflux symptoms, but it is not the most urgent instruction to emphasize at discharge.

Choice D reason: Remaining upright following meals is crucial for preventing reflux. Lying down immediately after eating can cause stomach contents to flow back into the oesophagus, exacerbating GERD symptoms. This instruction is key to managing the condition effectively.

A. Continue the normal saline IV at 75 mL/hour and encourage increased oral fluid intake. B. Slow the normal saline to a keep open rate while contacting the healthcare provider. C. Review the client's medications to see if the client can be given a PRN diuretic. D. Instruct the client to withhold oral fluids and report the symptoms to the provider.

Correct Answer is A

Explanation

Choice A reason: Continuing the normal saline IV at 75 mL/hour and encouraging increased oral fluid intake is the appropriate action. The client is showing signs of dehydration, such as dry mucous membranes and inelastic skin turgor, indicating a need for more fluids. Ensuring proper hydration through both IV and oral routes is essential.

Choice B reason: Slowing the normal saline to a keep open rate while contacting the healthcare provider is not appropriate in this situation. The client needs more fluids, not less. Reducing the IV rate could exacerbate dehydration.

Choice C reason: Reviewing the client's medications to see if the client can be given a PRN diuretic is not suitable for a client showing signs of dehydration. Diuretics would further decrease fluid volume and worsen the symptoms.

Choice D reason: Instructing the client to withhold oral fluids and report the symptoms to the provider is contrary to managing dehydration. The client needs increased fluid intake to address the signs of dehydration effectively.

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The practical nurse (PN) reports to the charge nurse that a client who is receiving a parenteral nutrition infusion has a capillary glucose of 365 mg/dL (20.3 mmol/L). Which action should the charge nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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A client who is receiving normal saline IV at 75 mL/hour has dry, sticky mucous membranes, and inelastic skin turgor. Which action should the nurse implement?

Correct Answer is A

Explanation

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