Nokea
A client with type 1 DM has a finger stick glucose level of 258mg/dl at bedtime. An order for sliding scale insulin exists. The nurse should:
- A. Call the physician
- B. Encourage the intake of fluids
- C. Administer the insulin as ordered
- D. Give the client ½ cup of orange juice
Correct Answer: C
Rationale: In this scenario, the client with type 1 DM has a high glucose level at bedtime. The appropriate action for the nurse is to administer the sliding scale insulin as ordered. This insulin regimen is specifically designed to manage high blood glucose levels. Calling the physician is not necessary as the protocol for sliding scale insulin is already in place. Encouraging fluid intake or providing orange juice is not the correct intervention for addressing high blood glucose levels in this case.
You may also like to solve these questions
Rotating injection sites when administering insulin prevents which of the following complications?
- A. Insulin edema
- B. Insulin lipodystrophy
- C. Insulin resistance
- D. Systemic allergic reactions
Correct Answer: B
Rationale: Rotating injection sites when administering insulin helps prevent insulin lipodystrophy, which is the abnormal distribution of fat at injection sites. Insulin edema (choice A) is not prevented by rotating injection sites; it is characterized by swelling at the site of insulin injection due to increased capillary permeability. Insulin resistance (choice C) is a condition where the body's cells become less responsive to insulin, and rotating injection sites does not directly prevent this. Systemic allergic reactions (choice D) are not specifically prevented by rotating injection sites; they are related to an allergic response to insulin.
A nurse working on a med-surg unit is managing the care of four clients. The nurse should schedule an interdisciplinary conference for which of the following clients?
- A. A client who is at risk for pressure ulcers and has an albumin level of 4.2 g/dL
- B. A client with type 1 DM who uses an insulin pump
- C. A client who is receiving heparin and has an aPTT of 34 seconds
- D. A client with orthostatic hypotension receiving IV fluids
Correct Answer: C
Rationale: The nurse should schedule an interdisciplinary conference for a client who is receiving heparin and has an aPTT of 34 seconds to ensure comprehensive care coordination. In this case, the need for a conference may be to discuss potential adjustments in heparin therapy, monitor for adverse effects, or ensure proper anticoagulation levels. Choices A, B, and D do not specifically indicate the need for interdisciplinary collaboration related to the client's condition or treatment. Therefore, they are not the priority for scheduling an interdisciplinary conference.
A nurse manager is leading a discussion about ethical dilemmas. Which of the following situations should the nurse manager include as an example of an ethical dilemma?
- A. A visitor experiences a minor burn after spilling coffee
- B. A client receives an operation on the wrong side of her body
- C. A parent wants her 14-year-old adolescent to receive radiation treatment against his will
- D. A nurse witnesses another nurse administer an incorrect medication
Correct Answer: C
Rationale: An ethical dilemma involves a situation where moral principles conflict, such as in the case of a parent wanting their adolescent to receive treatment against their will. In option A, a minor burn from spilled coffee does not present a conflict of moral principles. Option B describes a medical error, not necessarily a conflict of moral principles. Option D involves an issue of professional practice and patient safety but does not inherently pose a conflict of moral principles.
A nurse in the emergency department is assessing a client who is unconscious following a motor-vehicle crash. The client requires immediate surgery. Which of the following actions should the nurse take?
- A. Transport the client to the operating room without verifying informed consent
- B. Ask the anesthesiologist to sign the consent
- C. Obtain telephone consent from the facility administrator before the surgery
- D. Delay the surgery until the nurse can obtain informed consent
Correct Answer: A
Rationale: In emergency situations where a client is unconscious and requires immediate surgery, implied consent applies. Implied consent allows healthcare providers, including nurses, to proceed with necessary treatment or surgery without formally verifying informed consent. Choice A is correct because the priority in this scenario is to ensure the client receives timely medical intervention to address life-threatening conditions. Choices B, C, and D are incorrect because in emergencies, waiting to obtain formal consent can delay critical treatment, risking the client's health and well-being.
A nurse is supervising an assistive personnel (AP) who is feeding a client who has dysphagia. Which of the following actions by the AP should the nurse identify as correct technique?
- A. Elevating the head of the client's bed to 30 degrees during mealtime
- B. Withholding fluids until the end of the meal
- C. Providing a 10-minute rest period prior to meals
- D. Instructing the client to place her chin toward her chest when swallowing
Correct Answer: D
Rationale: The correct technique for a client with dysphagia is to instruct them to place their chin toward their chest when swallowing. This action helps to close off the airway during swallowing, reducing the risk of aspiration. Elevating the head of the client's bed to 30 degrees during mealtime helps prevent aspiration, but this is not the responsibility of the AP. Withholding fluids until the end of the meal can lead to dehydration and is not a recommended practice. Providing a 10-minute rest period prior to meals is not specifically related to improving swallowing safety for clients with dysphagia.