Questions 43

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NCLEX RN Questions on Endocrine System Questions

Extract:

The following scenario applies to the next 1 items
The nurse in the medical-surgical unit is caring for a 59-year-old female
Item 1 of 1
Nurses' Notes
0845: Morning capillary blood glucose obtained of 189 mg/dL (10.4 mmol/L). 4 units of lispro insulin administered per sliding scale. Vancomycin infusion started at this time in left peripheral vascular access device that was patent with positive blood return. Call bell placed within reach.

0950: The client alerted RN that they 'didn't feel good.' The client appeared pale, diaphoretic, and lethargic. The client's words became slurred, and she was disoriented, asking, "where am I?" 'The client's breakfast tray appeared untouched. The client's capillary blood glucose was obtained at 41 mg/dL (2.2 mmol/L). Glasgow coma scale: 13. Vital signs: T 98° F (36.7° C), P 108, RR 22, BP 150/86, pulse oximetry reading 95%. A rapid response was called because of the client's condition change.

1000: Rapid response team arrived at the bedside. Report was given to the rapid response nurse.

Medical History
• Diabetes mellitus, type I
• Hyperlipidemia
• Pericarditis
• Asthma
Orders
0700:
• Admit to medical/surgical for cellulitis
• vancomycin 1 g, IV, every 12 hours
• Resume all home medications
• Insulin lispro, sliding scale, before meals
• Consistent carbohydrate diet
• Daily labs: complete blood count and comprehensive metabolic panel


Question 1 of 5

The rapid response nurse receives report from the primary nurse and reviews the medical record. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress.

Action to Take

Keep the client NPO until mental status improves
Administer glucagon 1 mg intramuscular (IM)
Have the client drink 8 ounces (240 mL) of skim milk
Stop the vancomycin infusion.

Potential Condition

Creatinine
Glasgow coma scale
Capillary blood glucose
Urinary ketones.

Parameter to Monitor

Cerebrovascular accident
Diabetic ketoacidosis (DKA)
Hypoglycemia
Vancoymycin infusion reaction.

Correct Answer: C, B, C, B

Rationale: Low glucose (41 mg/dL), pallor, and disorientation indicate hypoglycemia. Administer glucagon for rapid correction, monitor glucose and Glasgow coma scale to assess recovery.

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Question 2 of 5

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Question 5 of 5

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