what is the priority action when a nurse misreads a glucose reading and administers excess insulin

ATI RN

ATI Capstone Adult Medical Surgical Assessment 2

1. What is the priority action when a healthcare professional misreads a glucose reading and administers excess insulin?

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

Correct answer: C

Rationale: The priority action when a healthcare professional misreads a glucose reading and administers excess insulin is to monitor for hypoglycemia. Excess insulin can lead to dangerously low blood sugar levels (hypoglycemia), which can result in serious complications. Monitoring for hypoglycemia allows for timely identification and intervention to prevent harm. Administering IV glucose may be necessary if hypoglycemia occurs. Monitoring for hyperglycemia is not the priority in this situation, as excess insulin would lower blood sugar levels. Documenting the incident is important for reporting and quality improvement purposes but should not take precedence over ensuring patient safety by monitoring for hypoglycemia.

2. A client who has burn injuries covering their upper body is concerned about their altered appearance. Which of the following statements should the nurse make?

A. It is okay to not want to touch the burned areas of your body.
B. Cosmetic surgery should be performed within the next year to be effective.
C. Reconstructive surgery can completely restore your previous appearance.
D. It could be helpful for you to attend a support group for people who have burn injuries.

Correct answer: D

Rationale: The nurse should encourage the client to attend a support group for individuals who have burn injuries. Support groups can provide emotional support, shared experiences, and coping strategies for accepting their altered appearance. Choice A is not the best response as it does not offer proactive support. Choice B is not appropriate as the timing of cosmetic surgery should be determined by healthcare providers, not immediate. Choice C is misleading as reconstructive surgery may improve appearance but may not completely restore the previous look.

3. What are the expected signs of increased intracranial pressure (IICP)?

A. Restlessness, confusion, irritability
B. Severe headache and confusion
C. Elevated blood pressure and bradycardia
D. Bradycardia and altered pupil response

Correct answer: A

Rationale: The correct answer is A: Restlessness, confusion, irritability. These are early signs of increased intracranial pressure (IICP) and require prompt intervention. Restlessness, confusion, and irritability are indicative of the brain's attempt to compensate for the rising pressure. Choice B is incorrect because severe headache alone is not specific to IICP and can be present in various conditions. Choice C is incorrect because elevated blood pressure is not a common sign of IICP; instead, hypertension may be present in the compensatory stage. Choice D is incorrect as bradycardia and altered pupil response are signs of advanced IICP, not early signs. Monitoring and recognizing these early signs are crucial for timely intervention and preventing further complications.

4. What teaching should be provided after cataract surgery?

A. Avoid NSAIDs
B. Wear dark glasses outdoors
C. Creamy white drainage is normal
D. Avoid bright lights

Correct answer: A

Rationale: The correct teaching that should be provided after cataract surgery is to avoid NSAIDs. NSAIDs should be avoided to prevent bleeding, especially in the eye area. While wearing dark glasses outdoors is important to protect the eyes, it is not the most critical teaching after cataract surgery. Creamy white drainage being normal is not relevant to post-cataract surgery teaching. Avoiding bright lights is generally recommended for patients with certain eye conditions but is not a specific teaching point after cataract surgery.

5. What is the first-line treatment for a patient experiencing wheezing and coughing due to an allergic reaction?

A. Albuterol via nebulizer
B. Methylprednisolone 100 mg IV
C. Cromolyn 20 mg via nebulizer
D. Aminophylline 500 mg IV

Correct answer: A

Rationale: The correct answer is A: Albuterol via nebulizer. Albuterol is the first-line treatment for wheezing caused by an allergic reaction as it quickly opens the airways, providing rapid relief. Choice B, Methylprednisolone 100 mg IV, is a systemic corticosteroid that may be used in severe cases to reduce inflammation but is not the initial treatment for acute wheezing. Choice C, Cromolyn 20 mg via nebulizer, is a mast cell stabilizer that is more commonly used for prophylaxis rather than acute relief in allergic conditions. Choice D, Aminophylline 500 mg IV, is a bronchodilator that is less commonly used now due to its narrow therapeutic window and potential for toxicity, making it less preferred than Albuterol for initial treatment of wheezing.