Nokea
A client's 12:00 noon blood glucose concentration was inaccurately documented as 310 instead of 130. This error was not noticed until 1:00 p.m. The nurse administered the sliding scale insulin for a blood glucose of 310 instead of 130. What should the nurse do first?
- A. Notify the physician.
- B. Assess for hypoglycemia.
- C. Consult with the clinical pharmacist.
- D. Call the charge nurse.
Correct Answer: B
Rationale: Administering insulin for a falsely high glucose level risks hypoglycemia, so assessing for symptoms (e.g., shakiness, sweating) is the priority.
You may also like to solve these questions
The nurse is assessing a client with a history of heart failure who is receiving a 500-mL I.V. bolus of 0.9% normal saline. To evaluate the client's response to the treatment, the nurse should especially monitor the client for which of the following?
- A. Hypotension.
- B. Increased urine output.
- C. Crackles in the lungs.
- D. Dry mucous membranes.
Correct Answer: C
Rationale: In heart failure, fluid boluses can lead to pulmonary edema, so monitoring for lung crackles is critical to detect fluid overload.
As the nurse in a primary care clinic, which cultural concern would you integrate into your psychological assessments of your clients?
- A. The concern related to the client's cultural reluctance to report psychological symptoms because of some possible culturally based stigma associated with psychiatric mental health disorders
- B. Concerns revolving around the lack of financial and health insurance resources to pay for psychological care
- C. Concerns related to the compliance with psychological treatment regimens because of the client's lack of social support systems
- D. The concern related to the culturally based client apathy about nursing care and nursing assessments
Correct Answer: A
Rationale: Cultural stigma around mental health can significantly impact clients' willingness to report psychological symptoms, making it a critical consideration in assessments.
The nurse is assessing a client with suspected appendicitis. Which test should the nurse perform to confirm the diagnosis?
- A. Rovsing's sign
- B. Murphy's sign
- C. Psoas sign
- D. Both A and C
Correct Answer: D
Rationale: Rovsing's sign (pain in the right lower quadrant with left-sided pressure) and psoas sign (pain with leg extension) support an appendicitis diagnosis.
Which federal law is most closely associated with the highly restrictive 'need to know'?
- A. The Patient Self Determination Act
- B. The Mental Health Parity Act
- C. The Health Insurance Portability and Accountability Act
- D. The Americans with Disabilities Act of 1990
Correct Answer: C
Rationale: The Health Insurance Portability and Accountability Act (HIPAA) enforces the 'need to know' principle, restricting access to protected health information to only those who require it for their job functions.
The nurse is assessing a client who has had a myocardial infarction. The nurse notes the cardiac rhythm shown below (see figure). The nurse identifies this rhythm as:
- A. Atrial fibrillation.
- B. Atrial tachycardia.
- C. Premature ventricular contractions.
- D. Ventricular tachycardia.
Correct Answer: C
Rationale: Premature ventricular contractions (PVCs) are characterized by early, wide QRS complexes on an ECG, common post-myocardial infarction. The other rhythms have distinct ECG patterns not described here.