0730

• Admit to the surgical floor
• Dextrose 59% and 0.9% sodium chloride to infuse at 125 ml/hr
• Advance diet as tolerated
• Insulin glargine 12 units subcutaneous every 12 hours
• Ceftriaxone 2 g IV every 24 hours for 3 days, first dose given in surgery
• Insulin lispro 1 unit subcutaneously per 15 carbohydrates
• Insulin lispro sliding scale:

180-240 mg/dL (10-13.3 mmol/L)- 1 unit

241-300 mg/dl. (13.4-16.7 mmol/L)-2 units

300-360 mg/dL (16.7-30 mmol/L)-3 units

over 360 mg/dL (30 mmol/L)-call the physician

• Glucagon 1 syringe subcutaneously for blood glucose less than 60 mg/dL (3.3 mmol/L) and unresponsiveness

It is 1800, and the client has a schedule dose of insulin glargine due. The client has a regular diet tray ordered with 60 carbohydrates. The tray has not yet arrived in the room.

For each nursing action below, click to specify If the action is indicated, contraindicated or non-essential.

A.While administering a second dose of naloxone (choice A) may be considered, the priority is to address the client's immediate life-threatening condition by starting CPR. Naloxone may be administered as part of the resuscitation effort.

B.Assessing the Glasgow Coma Scale (choice B) is important but not the first action to take when the client is in such severe distress. The priority is to address the inadequate breathing and oxygenation.

C.Preparing for chest tube insertion (choice C) may not be relevant in this situation. The primary concern is the client's respiratory and circulatory status.

In a situation where a client has received naloxone for opioid-induced respiratory depression and the client's condition worsens with a respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and an inability to be aroused, the nurse should:

D. Initiate cardiopulmonary resuscitation (CPR).

Explanation:

These vital signs indicate severe respiratory distress and potential respiratory failure. The low oxygen saturation (75%) suggests inadequate oxygenation, and a respiratory rate of 4 breaths/minute is dangerously low. The inability to be aroused may indicate a severe level of respiratory depression. In such a critical situation, CPR should be initiated to maintain oxygenation and circulation while waiting for additional medical assistance.

A. Breastfeeding is not recommended while taking this medication:

While it's important to avoid breastfeeding while taking isotretinoin due to potential risks to the infant, the priority in this scenario is preventing exposure to the medication during pregnancy.

The most important information for the nurse to provide to a young adult female client planning to become pregnant while taking isotretinoin for cystic acne is:

B. Discontinue this medication one month before attempting to conceive.

Explanation: Isotretinoin (commonly known as Accutane) is a teratogenic medication, which means it can cause severe birth defects if taken during pregnancy. Therefore, it is crucial for the client to discontinue this medication well before attempting to conceive. The recommended time frame to wait after stopping isotretinoin before attempting conception varies but is generally at least one month. The specific duration should be discussed with the healthcare provider.

C. Do not take multiple vitamins that contain vitamin A while taking this drug:

Avoiding excessive vitamin A intake is important to prevent vitamin A toxicity, but it is not the most critical piece of information for a client planning to become pregnant while on isotretinoin.

D. Baseline liver function results must be obtained during therapy:

Monitoring liver function is important during isotretinoin therapy, but the priority in this scenario is preventing fetal exposure to the medication by discontinuing it before attempting pregnancy.