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NurseDive Free Nursing Practice Question
At 8 a.m. the nurse is reviewing patient assignments and notes one of the patients has a current blood glucose of 264. Breakfast is routinely served at 8:30. The following orders are noted in the chart. What action should the nurse take? Accucheck before meals and at bedtime with sliding scale insulin aspart SQ: Glucose 0-150 Administer 0 units; 151-200 Administer 2 units; 201-250 Administer 4 units: 251-300 Administer 6 units: 301-350 Administer 8 units; 351- 400 Administer 10 units; >400 Notify physician.
A. Provide 2 units insulin aspart 50
This option corresponds to the blood glucose range of 151-200. However, the patient's current blood glucose level is 264, which falls into the range of 251-300. Therefore, administering 2 units would not be appropriate in this case.
B. Provide 6 units insulin aspart 50
The patient's current blood glucose level is 264, which falls into the range of 251-300. According to the sliding scale insulin aspart orders, for this range, 6 units should be administered. This option aligns with the patient's blood glucose level and the prescribed protocol.
C. Provide 10 units insin apart SQ
This option corresponds to the blood glucose range of 351-400. The patient's blood glucose level of 264 does not fall into this range, so administering 10 units would be excessive and potentially lead to hypoglycemia.
D. Provide 4 units insulin aspart 50
This option corresponds to the blood glucose range of 201-250. The patient's current blood glucose level is 264, which falls into the range of 251-300. Therefore, administering 4 units would not be sufficient to address the elevated blood glucose level.
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Full Explanation
A. This option corresponds to the blood glucose range of 151-200. However, the patient's current blood glucose level is 264, which falls into the range of 251-300. Therefore, administering 2 units would not be appropriate in this case.
B. The patient's current blood glucose level is 264, which falls into the range of 251-300. According to the sliding scale insulin aspart orders, for this range, 6 units should be administered. This option aligns with the patient's blood glucose level and the prescribed protocol.
C. This option corresponds to the blood glucose range of 351-400. The patient's blood glucose level of 264 does not fall into this range, so administering 10 units would be excessive and potentially lead to hypoglycemia.
D. This option corresponds to the blood glucose range of 201-250. The patient's current blood glucose level is 264, which falls into the range of 251-300. Therefore, administering 4 units would not be sufficient to address the elevated blood glucose level.
Similar Questions
When preparing to provide morning medications, the nurse would give levothyroxine (Synthroid) ordered daily in which of the following ways?
A. in the morning with breakfast
This option is not ideal for levothyroxine (Synthroid) because it should be taken on an empty stomach for optimal absorption. Taking it with food, especially a meal like breakfast, can interfere with its absorption.
B. in the morning on an empty stomach with other daily meds
This is the correct option. Levothyroxine should be taken in the morning, at least 30 minutes before breakfast or any other medications. Taking it on an empty stomach ensures the best absorption of the medication.
C. in the evening with a snack
Taking levothyroxine in the evening is not recommended. It should be taken in the morning to coincide with the body's natural circadian rhythm and to avoid potential interactions with food or other medications.
D. the morning before breakfast and without any other medications
While it's important to take levothyroxine in the morning before breakfast, it is not necessary to take it without any other medications. It can be taken alongside other daily medications as long as there are no interactions that would affect its absorption.
Full Explanation
A. This option is not ideal for levothyroxine (Synthroid) because it should be taken on an empty stomach for optimal absorption. Taking it with food, especially a meal like breakfast, can interfere with its absorption.
B. This is the correct option. Levothyroxine should be taken in the morning, at least 30 minutes before breakfast, or any other medications. Taking it on an empty stomach ensures the best absorption of the medication.
C. Taking levothyroxine in the evening is not recommended. It should be taken in the morning to coincide with the body's natural circadian rhythm and to avoid potential interactions with food or other medications.
D. While it's important to take levothyroxine in the morning before breakfast, it is not necessary to take it without any other medications. It can be taken alongside other daily medications as long as there are no interactions that would affect its absorption.
A nurse is assessing a client who has hypothyroidism. The nurse should expect which of the following findings?
A. Palpitations
Incorrect. Palpitations, which are rapid or irregular heartbeats, are more commonly associated with hyperthyroidism, where there is an excess of thyroid hormones.
B. Diaphoresis
Incorrect. Diaphoresis, or excessive sweating, is not typically associated with hypothyroidism.
C. Exophthalmos
C. Incorrect. Exophthalmos, or bulging of the eyes, is a characteristic finding in hyperthyroidism (specifically Graves' disease) and is not typically seen in hypothyroidism.
D. Weight gain
Correct. Weight gain is a common finding in hypothyroidism. The slowing down of metabolic processes due to insufficient thyroid hormones can lead to an increase in body weight.
Full Explanation
A. Incorrect. Palpitations, which are rapid or irregular heartbeats, are more commonly associated with hyperthyroidism, where there is an excess of thyroid hormones.
B. Incorrect. Diaphoresis, or excessive sweating, is not typically associated with hypothyroidism.
C. Incorrect. Exophthalmos, or bulging of the eyes, is a characteristic finding in hyperthyroidism (specifically Graves' disease) and is not typically seen in hypothyroidism.
D. Correct. Weight gain is a common finding in hypothyroidism. The slowing down of metabolic processes due to insufficient thyroid hormones can lead to an increase in body weight.
The nurse is assessing an older patient with type 2 diabetes mellitus. What age-related endocrine change should the nurse expect in this patient?
A. More rapid insulin release
Incorrect. Aging is associated with a decrease in insulin production and a reduction in the speed of insulin release, not an increase.
B. intolerance of fatty foods
Incorrect. Intolerance of fatty foods is not typically an age-related endocrine change. It may be related to other factors such as digestive issues.
C. Decreased sensitivity to insulin
Correct. Decreased sensitivity to insulin is a common age-related endocrine change, particularly in individuals with type 2 diabetes mellitus.
D. Lower and prolonged blood glucose levels
Incorrect. Lower and prolonged blood glucose levels are not an expected age-related endocrine change. Instead, insulin resistance tends to result in elevated blood glucose levels.
Full Explanation
A. Incorrect. Aging is associated with a decrease in insulin production and a reduction in the speed of insulin release, not an increase.
B. Incorrect. Intolerance of fatty foods is not typically an age-related endocrine change. It may be related to other factors such as digestive issues.
C. Correct. Decreased sensitivity to insulin is a common age-related endocrine change, particularly in individuals with type 2 diabetes mellitus.
D. Incorrect. Lower and prolonged blood glucose levels are not an expected age-related endocrine change. Instead, insulin resistance tends to result in elevated blood glucose levels.