a nurse misreads a glucose reading and administers insulin for a blood glucose of 210 instead of 120 what should the nurse monitor the patient for

ATI RN

ATI Capstone Medical Surgical Assessment 2 Quizlet

1. A nurse misreads a glucose reading and administers insulin for a blood glucose of 210 instead of 120. What should the nurse monitor the patient for?

A. Monitor for hyperglycemia
B. Monitor for signs of hypoglycemia
C. Administer glucose IV
D. Document the incident

Correct answer: B

Rationale: The correct answer is B: Monitor for signs of hypoglycemia. The nurse should monitor the patient for hypoglycemia due to the administration of excess insulin. Administering insulin for a blood glucose level of 210 instead of 120 can lead to a rapid drop in blood sugar levels, causing hypoglycemia. Option A is incorrect as hyperglycemia is high blood sugar, which is unlikely in this scenario. Option C is incorrect as administering glucose IV would worsen the hypoglycemia. Option D is not the immediate priority; patient safety and monitoring for adverse effects take precedence.

2. What is an escharotomy and when is it performed?

A. A surgical incision to release pressure in burn injuries
B. A procedure to remove dead tissue from wounds
C. An incision to improve circulation in tight skin after burns
D. A procedure to remove excess fluid from the chest

Correct answer: A

Rationale: An escharotomy is a surgical incision made to release pressure in a part of the body that has a deep burn and excessive swelling. This procedure is crucial in preventing further damage due to restricted blood flow and compromised circulation. Choice B is incorrect because it describes debridement, which is the removal of dead tissue from wounds. Choice C is incorrect as it does not specifically address the purpose of relieving pressure in burn injuries. Choice D is incorrect as it describes a procedure more related to thoracentesis, which is the removal of excess fluid from the chest, typically the pleural space.

3. What is the priority action if a patient experiences abdominal cramping during enema administration?

A. Lower the height of the solution container
B. Increase the flow of the enema solution
C. Stop the procedure and remove the tubing
D. Continue the enema at a slower rate

Correct answer: A

Rationale: During enema administration, if a patient experiences abdominal cramping, the priority action is to lower the height of the solution container. This adjustment can help relieve abdominal cramping by reducing the flow rate of the enema, making it more comfortable for the patient. Increasing the flow of the enema solution (Choice B) can exacerbate the cramping. Stopping the procedure and removing the tubing (Choice C) may be necessary in some cases of severe discomfort or complications, but adjusting the height of the solution container should be the initial response. Continuing the enema at a slower rate (Choice D) may not address the immediate need to alleviate the cramping.

4. What are the expected symptoms in a patient experiencing a thrombotic stroke?

A. Gradual loss of function on one side of the body
B. Sudden loss of consciousness
C. Seizures and convulsions
D. Severe headache and vomiting

Correct answer: A

Rationale: The correct answer is A: 'Gradual loss of function on one side of the body.' Thrombotic strokes typically result in a gradual onset of symptoms due to a blockage in a blood vessel in the brain, leading to a slow progression of neurological deficits. Choices B, C, and D are incorrect because sudden loss of consciousness, seizures, convulsions, severe headache, and vomiting are more commonly associated with other types of strokes or medical conditions, such as hemorrhagic strokes, epilepsy, or migraines.

5. What dietary recommendations should be provided to a patient with GERD?

A. Avoid mint and spicy foods
B. Eat large meals before bed
C. Consume liquids with meals
D. Avoid foods high in potassium

Correct answer: A

Rationale: The correct recommendation for a patient with GERD is to avoid mint and spicy foods. These types of foods can trigger acid reflux and worsen GERD symptoms. Choice B is incorrect as eating large meals before bed can increase the likelihood of acid reflux due to increased pressure on the lower esophageal sphincter. Choice C is also incorrect as consuming liquids with meals can cause distension in the stomach, potentially leading to reflux. Choice D is not directly related to GERD, as foods high in potassium are generally healthy and not specifically problematic for GERD patients.