a nurse misreads a glucose level and administers insulin for a blood glucose of 210 mgdl instead of 120 mgdl what is the priority intervention

ATI RN

ATI Capstone Adult Medical Surgical Assessment 2

1. 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?

A. Monitor for hypoglycemia
B. Monitor for hyperkalemia
C. Administer glucose IV
D. Document the incident

Correct answer: A

Rationale: The correct answer is to monitor for hypoglycemia. In this scenario, the nurse administered insulin based on a misread glucose level, which could lead to hypoglycemia due to excessive insulin action lowering blood glucose levels. Monitoring for hypoglycemia allows for prompt recognition and intervention if blood glucose levels drop significantly. Choice B, monitoring for hyperkalemia, is incorrect as administering insulin would not cause hyperkalemia. Choice C, administering glucose IV, is not appropriate at this time since the patient's blood glucose level is already elevated. Choice D, documenting the incident, is important but not the priority at this moment when patient safety is at risk due to potential hypoglycemia.

2. What are the dietary recommendations for a patient with pre-dialysis end-stage kidney disease?

A. Reduce phosphorus intake to 700 mg/day
B. Limit sodium intake to 1,500 mg/day
C. Restrict protein intake to 0.55-0.60 g/kg/day
D. Increase protein intake

Correct answer: A

Rationale: The correct recommendation for a patient with pre-dialysis end-stage kidney disease is to reduce phosphorus intake to 700 mg/day. High phosphorus levels can be harmful to individuals with kidney disease as the kidneys may not be able to filter it effectively. While limiting sodium intake to 1,500 mg/day and restricting protein intake to 0.55-0.60 g/kg/day are important in managing kidney disease, the primary concern for this patient population is to control phosphorus levels. Increasing protein intake is not recommended as it can put additional strain on the kidneys. Therefore, option A is the most appropriate recommendation in this scenario.

3. What precaution should be advised to a patient following a cataract surgery?

A. Wear dark glasses while outdoors
B. Avoid NSAIDs
C. Use warm compresses
D. Apply cold packs

Correct answer: A

Rationale: Following cataract surgery, patients are advised to wear dark glasses while outdoors. This is crucial to protect the eyes from bright light and prevent complications such as excessive glare or discomfort. Choice B, avoiding NSAIDs, is not directly related to post-cataract surgery care. Choices C and D, using warm compresses and applying cold packs, are not typically part of the standard post-operative care for cataract surgery.

4. A client scheduled for electromyography (EMG) will have small needle electrodes inserted into the muscles. What should the nurse include in the teaching?

A. You will receive a fixed dose of radioisotope 2 hours before the procedure.
B. Momentary flushing will occur at the beginning of the procedure.
C. You should inform your provider if you are claustrophobic.
D. You should expect insertion of small needle electrodes into the muscles.

Correct answer: D

Rationale: The correct answer is D. During an electromyography (EMG) procedure, small needle electrodes are inserted into the muscles to assess muscle weakness and nerve responses. Choices A, B, and C are incorrect because radioisotope is not used in EMG, flushing is not a typical occurrence, and claustrophobia is more relevant for imaging procedures like MRI or CT scans, not EMG.

5. What is an escharotomy and why is it performed?

A. A surgical incision made to improve circulation in burn injuries
B. A procedure to remove dead tissue from a wound
C. A procedure to remove excess fluid from the lungs
D. A procedure to relieve pain from burns

Correct answer: A

Rationale: An escharotomy is a surgical procedure involving an incision through the eschar (dead tissue) to relieve pressure in burn injuries. It is performed to improve circulation to the affected area, prevent further damage, and restore blood flow. Choice B is incorrect because an escharotomy is not primarily focused on removing dead tissue but rather on relieving pressure. Choice C is incorrect as it describes a procedure related to pulmonary issues, not burn injuries. Choice D is incorrect because while pain relief may be a result of an escharotomy, it is not the primary purpose of the procedure.