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 ECG change is associated with hyperkalemia?

A. Flattened T waves
B. ST depression
C. Prominent U waves
D. Elevated ST segments

Correct answer: B

Rationale: The correct ECG change associated with hyperkalemia is ST depression. Hyperkalemia typically presents with ECG changes such as peaked T waves, prolonged PR interval, widened QRS complex, and finally, ST segment depression. Flattened T waves are more commonly associated with hypokalemia. Prominent U waves are seen in hypokalemia as well. Elevated ST segments are not a typical ECG finding in hyperkalemia.

3. What symptoms are associated with a thrombotic stroke?

A. Gradual loss of function on one side of the body
B. Sudden loss of consciousness
C. Loss of motor function with nausea
D. Severe headache and vomiting

Correct answer: A

Rationale: A thrombotic stroke presents with a gradual loss of function on one side of the body due to a clot blocking blood flow to the brain. This gradual onset distinguishes it from a hemorrhagic stroke with sudden symptoms like loss of consciousness (Choice B), and from other conditions like migraine, which may present with severe headache and vomiting (Choice D). Nausea (Choice C) is not typically a primary symptom associated with a thrombotic stroke.

4. A nurse is planning care for a group of postoperative clients. Which of the following interventions should the nurse identify as the priority?

A. Administer IV pain medication to a client who reports pain as a 6 on a scale of 0 to 10
B. Administer oxygen to a client who has an oxygen saturation of 91%
C. Instruct a client who is 1 hr postoperative about coughing and deep breathing exercises
D. Initiate an infusion of 0.9% sodium chloride for a client who has just had abdominal surgery

Correct answer: B

Rationale: The priority intervention is administering oxygen. Postoperatively, the client's oxygen saturation should be at or above 95%. Oxygen is essential for tissue perfusion and cellular oxygenation. While managing pain is important, oxygenation takes precedence. Instructing a client about coughing and deep breathing exercises is important for preventing respiratory complications but is not as urgent as addressing low oxygen saturation. Initiating an infusion of 0.9% sodium chloride is a routine postoperative intervention for fluid balance but is not the priority when oxygen saturation is low.

5. What should be monitored in a patient receiving insulin who is at risk for hypoglycemia?

A. Monitor blood glucose levels
B. Monitor for respiratory distress
C. Monitor for hypertension
D. Monitor for hyperkalemia

Correct answer: A

Rationale: Corrected Question: In a patient receiving insulin who is at risk for hypoglycemia, monitoring blood glucose levels is crucial. This helps in preventing and identifying hypoglycemia promptly. Choice B, monitoring for respiratory distress, is not directly related to hypoglycemia caused by insulin. Choice C, monitoring for hypertension, is not typically associated with hypoglycemia. Choice D, monitoring for hyperkalemia, is not a common concern in patients receiving insulin who are at risk for hypoglycemia.