Difficulty: Medium
Average Score: 92%
Simulated
Passage / Scenario
Nurse's Notes & Physical ExaminationÔÇó The client arrived in the emergency department with complaints of fatigue, blurred vision, dizziness, and headache for the past two days. They report running out of blood glucose strips and insulin due to financial constraints. The client appears tired, is cooperative, and has a slightly dry mucous membrane. They are oriented to person, place, and time but seem concerned about their health status. The skin is warm and dry to the touch, with no visible rashes or lesions. Heart sounds are regular without murmurs; breath sounds are clear bilaterally. The abdomen is soft with no tenderness upon palpation. The client expresses anxiety about potential falls due to dizziness.
Vital Signs
ÔÇó Blood Pressure: 120/72 mm Hg
ÔÇó Temperature: 36.8┬░ C (98.2┬░ F)
ÔÇó Pulse: 88/min
ÔÇó Respirations: 20/min
Diagnostic Results
ÔÇó Blood Glucose: 235 mg/dL (Reference range: 74-106 mg/dL)
ÔÇó HbA1c: 8.4% (Target for diabetics: <7%)
ÔÇó Hemoglobin: 14.2 g/dL (12-18 g/dL)
ÔÇó Hematocrit: 42.6% (37-52%)
ÔÇó WBC Count: 6000/mm┬│ (5000-10,000/mm┬│)
Provider's Prescriptions
ÔÇó Increase glargine from 20 units to 25 units at bedtime.
ÔÇó Continue other home medications as prescribed.
Scenario: A nurse is caring for a client admitted to the medical-surgical unit. The exhibits below detail the client's condition at different time points throughout the day. Review the exhibits and determine how the patient's condition evolves and whether it worsens or improves. The initial data is recorded at 0700 hrs, followed by subsequent observations at different times.
Based on the initial assessment and diagnostic results, what is the priority nursing intervention?
Correct answer
A
Rationale
The correct answer is A: Administer a bolus of IV fluids. The priority nursing intervention is to address any immediate physiological needs identified in the initial assessment and diagnostic results. Administering IV fluids can help stabilize the client's fluid and electrolyte balance, ensuring proper circulation and organ function. This intervention takes precedence over the other options as it directly addresses a critical aspect of the client's condition. Administering insulin (choice B) may be necessary for managing specific conditions but is not the immediate priority. Oxygen therapy (choice C) may be beneficial, but if the client is in need of fluid resuscitation, addressing hypovolemia takes precedence. Fall precautions and providing a bedside commode (choice D) are important for safety but do not address the physiological needs identified in the initial assessment.