Level: Foundational
Difficulty: Easy
Subtopic: Cardiac medications
NCLEX: A 55-year-old client in postanesthesia care is being evaluated for heart failure and diuretic therapy. Assessment…
Pharmacology Pharmacological and Parenteral Therapies
Case Study
A 55-year-old client in postanesthesia care is being evaluated for heart failure and diuretic therapy. Assessment data include blood glucose 54 mg/dL with diaphoresis and confusion. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. The new finding that blood glucose 54 mg/dL with diaphoresis and confusion.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
B. The new finding that blood glucose 54 mg/dL with diaphoresis and confusion.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: B. The new finding that blood glucose 54 mg/dL with diaphoresis and confusion.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.