Correct Answer: B

Rationale: Staying with the patient and rechecking blood glucose delays immediate corrective action required for severe hypoglycemia (40 mg/dL). While safety is important, prompt treatment with glucose is the priority to prevent further complications. Following the hypoglycemia protocol ensures immediate glucose administration, either orally, intravenously, or intramuscularly, to stabilize the patient. This is critical as glucose levels below 40 mg/dL require urgent intervention to prevent neuronal damage or coma. Monitoring and rechecking glucose after treating is essential but not sufficient as the first action. Hypoglycemia this severe needs immediate treatment before monitoring, ensuring prompt glucose replacement to prevent worsening symptoms. Notifying the physician without treating the hypoglycemia risks unnecessary delays. Immediate action, such as administering glucose per protocol, is vital in this emergency scenario for patient safety.

Correct Answer: B

Rationale: Estimating carbohydrate content rather than measuring can lead to inaccuracies in blood sugar control for diabetic patients. Precise carbohydrate counting is essential for maintaining glycemic control and preventing hyperglycemia or hypoglycemia, making this approach unsuitable in diabetes education. Balancing carbohydrate intake with insulin or medication is a critical aspect of diabetes management. This ensures stable blood glucose levels as insulin dosage or medication is adjusted according to the patient's carbohydrate consumption, providing personalized glycemic control effectively. Avoiding all carbohydrates is not a realistic or scientifically sound recommendation, as carbohydrates are essential for energy production. Teaching portion control and healthy carbohydrate choices is more effective for diabetic management than complete avoidance. Counting carbohydrates from sugary foods alone ignores the contribution of complex carbohydrates to blood glucose levels. A comprehensive approach that considers all sources of carbohydrates ensures accurate diabetes education and better long-term blood sugar control.

Correct Answer: C,D,E,F

Rationale: Assessing the range of motion of a severely injured leg is not appropriate during initial evaluation. Movement can worsen the injury or disrupt stabilizing measures such as splints or dressings. Asking the patient to stand or bear weight risks further injury and is contraindicated in cases of visible deformity or massive bleeding. Evaluating skin color helps identify potential ischemia, vascular compromise, or inadequate perfusion. Pallor or cyanosis can indicate significant circulation issues needing urgent care. Paresthesia (tingling or numbness) reflects nerve function and can reveal nerve damage or compromised blood flow, necessitating thorough evaluation. Pain assessment is crucial for identifying the severity of injury and potential complications such as compartment syndrome. Pain disproportionate to the injury suggests complications. Palpating pulses assesses blood flow, ensuring the presence of distal perfusion. Absent or weak pulses require urgent vascular intervention to prevent tissue necrosis.

Correct Answer: A,B,C

Rationale: Blood pressure of 85/55 indicates hypotension, which can compromise perfusion to vital organs such as the brain and kidneys. Immediate assessment is necessary to determine the underlying cause, such as dehydration or internal bleeding. Hemoglobin level of 7 g/dL is critically low, falling below the normal range of 12–16 g/dL for women or 13–18 g/dL for men. This reflects severe anemia, which may require urgent intervention, including blood transfusion or addressing the cause of anemia. Massive bleeding from the right lower leg is an emergency due to the risk of hypovolemic shock and significant blood loss. Stabilization of the bleeding site and monitoring for signs of systemic impact is required immediately. A temperature of 96.5°F (35.8°
C) may signal mild hypothermia or a systemic condition. While it requires follow-up, it is not as immediately life-threatening as the other findings and therefore does not warrant immediate prioritization.

Correct Answer: B

Rationale: Checking plantar and dorsiflexion assesses neurological status requiring nursing expertise and cannot be delegated to UAP. Log rolling every 2 hours maintains spinal alignment post-laminectomy, a straightforward, standardized task suitable for experienced UAP. PCA assessment involves evaluating pain control methods, which require critical nursing judgments and is not appropriate to delegate. Determining readiness to ambulate involves comprehensive assessment skills, evaluating multiple factors like pain, strength, and hemodynamic stability, beyond UAP's scope of practice.