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. What are the signs of compartment syndrome?

A. Unrelieved pain, pallor, pulselessness
B. Muscle weakness, hyporeflexia
C. Pins-and-needles sensation, swelling
D. Severe swelling and tightness in the affected extremity

Correct answer: A

Rationale: The correct signs of compartment syndrome include unrelieved pain, pallor, and pulselessness due to increased pressure within a muscle compartment. Choice B, muscle weakness, and hyporeflexia are not typical signs of compartment syndrome. Choice C, pins-and-needles sensation and swelling, are not specific signs of compartment syndrome. Choice D, severe swelling and tightness in the affected extremity, could be seen in compartment syndrome but are not the primary signs.

3. A nurse misreads a blood glucose level and administers excess insulin. What should the nurse monitor for?

A. Monitor for hyperglycemia
B. Monitor for hypoglycemia
C. Administer glucose IV
D. Monitor for increased thirst

Correct answer: B

Rationale: The correct answer is to monitor for hypoglycemia. Excess insulin can lead to low blood glucose levels, causing hypoglycemia. Symptoms of hypoglycemia include sweating, trembling, dizziness, confusion, and in severe cases, loss of consciousness. Options A, C, and D are incorrect because administering excess insulin would not lead to hyperglycemia or increased thirst, and administering glucose IV would exacerbate the issue by further lowering blood glucose levels.

4. A nurse is teaching a group of assistive personnel (AP) about caring for clients who have Alzheimer's disease. Which of the following information should the nurse include in the teaching?

A. Explain procedures clearly and concisely to the client before initiating care
B. Encourage a client's engagement in appropriate activities to minimize emotional outbursts
C. Speak calmly and at a moderate volume to a client who is unable to form words or sentences
D. Provide supervision to prevent a client from becoming injured or lost

Correct answer: D

Rationale: The correct answer is D because clients with Alzheimer's disease are at risk of wandering and becoming lost. Providing supervision helps prevent them from getting injured or lost. Choice A is incorrect because extensive details may overwhelm clients with Alzheimer's. Choice B is incorrect because limiting activities can lead to boredom and behavioral issues. Choice C is incorrect because speaking calmly and at a moderate volume helps to reduce agitation and confusion in clients with Alzheimer's.

5. What are the priority lab values to monitor in a patient with HIV?

A. CD4 T-cell count below 180 cells/mm3
B. White blood cell count
C. Hemoglobin levels
D. Serum albumin levels

Correct answer: A

Rationale: The correct answer is A: CD4 T-cell count below 180 cells/mm3. Monitoring the CD4 T-cell count is crucial in patients with HIV as it indicates the level of immunocompromise. A CD4 count below 180 cells/mm3 is considered severe immunocompromise and requires close monitoring and intervention. Choices B, C, and D are not the priority lab values to monitor in HIV patients. While white blood cell count, hemoglobin levels, and serum albumin levels can provide valuable information about the patient's health status, they are not as specific or indicative of HIV disease progression and management as the CD4 T-cell count.