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A nurse is reviewing a client’s laboratory results and notes a blood glucose result of 104 mg/dL (5.8 mmol/L). The reference range is 74 to 106 mg/dL (4.1 to 5.9 mmol/L). Which action should the nurse take?
- A. Place the client on contact precautions.
- B. Start a high-fiber diet.
- C. Administer an oral steroid.
- D. Make the client NPO.
Correct Answer: D
Rationale: Normal glucose requires no action.
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A nurse is reviewing a client’s orders and notes the following: Vital signs every 4 hours, regular diet, Cefazolin 1g IV every 8 hours for 5 days, Metformin 1,000 mg PO every 12 hours, and point of care blood glucose check every 4 hours. Which action should the nurse take?
- A. Place the client on contact precautions.
- B. Start a high-fiber diet.
- C. Administer an oral steroid.
- D. Make the client NPO.
Correct Answer: D
Rationale: Follow regular diet per orders.
The nurse is caring for a client with type 2 diabetes mellitus who had surgery for a large bowel resection with a colostomy placement. The client has now developed hyperglycemia which requires self-injections of insulin after discharge. When designing the postoperative plan of care, which outcome statement should the nurse use?
- A. The client will demonstrate the ability to change the ostomy bag in two days.
- B. The client attempts to self-administer insulin but is unable to perform the injection.
- C. The client’s breath sounds will be auscultated by the nurse every 4 hours.
- D. The client will adhere to the medication regimen after discharge.
Correct Answer: D
Rationale: Medication adherence manages hyperglycemia.
A child has experienced several episodes of vomiting. After the nurse reviews the need to provide only clear liquids, the parent of the child reports making clear liquid popsicles out of flavored gelatin for the child. Which information should the nurse obtain about the popsicles?
- A. How many popsicles are available.
- B. The color and flavor of gelatin used.
- C. If the popsicles are completely frozen.
- D. Whether they contain pulp or fruit.
Correct Answer: C
Rationale: Pulp or fruit ensures clear liquid compliance.
The primary nurse went on break at 1845. The covering nurse gave a second dose of insulin because of being unaware the primary nurse gave the ordered dose. Which error prevention techniques would have helped to avoid this?
- A. Double check all dosage calculations.
- B. nusually large or small doses.
- C. Compare the medication label to the order.
- D. Use at least 2 client identifiers before administering a dose.
- E. Involve and educate clients in medication administration.
- F. Document all medication in the electronic record as soon as it is given.
Correct Answer: A,C,D,E.F
Rationale: Documentation and verification prevent errors.
The nurse is teaching the client to self-administer a dose of low molecular weight heparin SUBQ. Which instruction should the nurse include?
- A. Expel the air in the prefilled syringe prior to injection.
- B. Rotate injections between the abdomen and gluteal areas.
- C. Massage the injection site to increase absorption.
- D. Inject in the abdominal area at least 2 inches from the umbilicus.
Correct Answer: D
Rationale: Abdominal site ensures absorption.