a nurse administers insulin for a misread glucose level what should the nurse monitor for
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Nursing Elites

ATI RN

ATI Capstone Medical Surgical Assessment 1 Quizlet

1. A nurse administers insulin for a misread glucose level. What should the nurse monitor for?

Correct answer: A

Rationale: When a nurse administers insulin for a misread glucose level, they should monitor for hypoglycemia. Insulin lowers blood sugar levels, so the patient may experience hypoglycemia if given insulin unnecessarily. Monitoring for hypoglycemia involves observing for symptoms such as shakiness, sweating, dizziness, confusion, and palpitations. Choices B and C are incorrect because administering insulin for a misread glucose level would lower blood sugar levels, resulting in hypoglycemia, not hyperglycemia or hyperkalemia. Choice D is not the immediate priority; the focus should be on patient safety and monitoring for potential adverse effects of the unnecessary insulin.

2. A patient with a chest tube has continuous bubbling in the water seal chamber. What does this indicate?

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber of a chest tube indicates an air leak. This situation requires immediate attention to prevent complications such as lung collapse. A blocked chest tube would typically result in absent or fluctuating bubbling. Drainage from the site would be observed in the collection chamber, not the water seal chamber. A blood clot in the chest tube would lead to cessation of drainage.

3. What is the priority lab value to monitor in a patient with HIV?

Correct answer: A

Rationale: The correct answer is A: CD4 T-cell count 180 cells/mm3. Monitoring the CD4 T-cell count is crucial in patients with HIV to assess the status of their immune system. A CD4 count of 180 cells/mm3 indicates severe immunocompromise and a high risk of opportunistic infections. This value is used to guide treatment decisions and assess the need for prophylaxis against specific infections. Choices B, C, and D are incorrect because monitoring white blood cell count, potassium levels, and hemoglobin levels, although important in HIV patients, are not as crucial as monitoring the CD4 T-cell count for assessing immune function and disease progression.

4. What is the appropriate electrical intervention for a patient with ventricular tachycardia and a pulse?

Correct answer: B

Rationale: Synchronized cardioversion is the correct electrical intervention for a patient with ventricular tachycardia and a pulse. This procedure delivers a synchronized electrical shock to the heart during a specific phase of the cardiac cycle, aiming to restore the heart's normal rhythm. Defibrillation (choice A) is used for pulseless ventricular tachycardia or ventricular fibrillation. Pacing (choice C) is typically used for bradycardias or certain types of heart blocks. Medication administration (choice D) may be used in some cases, but in the scenario of ventricular tachycardia with a pulse, synchronized cardioversion is the preferred intervention.

5. What symptoms are expected in a patient with compartment syndrome?

Correct answer: A

Rationale: In a patient with compartment syndrome, the key symptoms include unrelieved pain, pallor, and pulselessness. These symptoms indicate reduced circulation in the affected compartment. Choice B is incorrect as localized swelling and numbness are not typically associated with compartment syndrome. Choice C is incorrect as fever and infection are not primary symptoms of compartment syndrome. Choice D is incorrect as weakness and fatigue are not typically seen in compartment syndrome.

Similar Questions

What lab value should be prioritized in a patient with HIV?
A nurse is assessing a client who has a heart rate of 40/min. The client is diaphoretic and has chest pain. Which of the following medications should the nurse plan to administer?
A nurse misreads a glucose level and administers insulin for a blood glucose of 210 mg/dL instead of 120 mg/dL. What is the priority intervention?
What are the early signs of hypokalemia on an ECG?
What are the expected signs of compartment syndrome?

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