A client reports confusion and blurred vision after receiving a dose of glipizide. Which action should the nurse implement?

Choice A reason: Keeping an oral liquid or glucose source available is a good intervention for any client who is receiving insulin, as it can help treat hypoglycemia, which is a low blood sugar level. However, it is not the most important intervention for a client who is receiving insulin lispro, which is a rapid-acting insulin that starts working within 15 minutes and lasts for 2 to 4 hours. The nurse should ensure that the client has a meal ready before giving this insulin, as it can cause severe hypoglycemia if the client does not eat soon after.

Choice B reason: Providing meals at the same time this insulin is given is the most important intervention for a client who is receiving insulin lispro, which is a rapid-acting insulin that mimics the natural insulin response to a meal. The nurse should coordinate the timing of the insulin injection and the meal, as the insulin will lower the blood sugar level quickly and the meal will provide the glucose needed to prevent hypoglycemia. The nurse should also teach the client and the family about the importance of eating within 15 minutes of taking this insulin.

Choice C reason: Assessing for hypoglycemia between meals is a good intervention for any client who is receiving insulin, as it can help detect and treat low blood sugar levels. However, it is not the most important intervention for a client who is receiving insulin lispro, which is a rapid-acting insulin that has a short duration of action. The risk of hypoglycemia is highest during the peak of the insulin action, which is 30 to 90 minutes after the injection. The nurse should monitor the client's blood sugar level more frequently during this time and provide snacks as needed.

Choice D reason: Checking blood glucose levels every six hours is not a sufficient intervention for a client who is receiving insulin lispro, which is a rapid-acting insulin that requires more frequent monitoring. The nurse should check the blood glucose level before each meal and at bedtime, as well as before and after exercise, to adjust the insulin dose and prevent hyperglycemia or hypoglycemia. The nurse should also teach the client and the family how to use a glucometer and record the blood glucose results.

Choice A reason: This is not an assessment finding that warrants immediate intervention by the nurse. Blood pressure 100/78 mm Hg is within the normal range for an adult, and it does not indicate any adverse effect of phenytoin. The nurse should monitor the blood pressure for any changes, but it is not a priority.

Choice B reason: This is an assessment finding that warrants immediate intervention by the nurse. Double vision, or diplopia, is a sign of phenytoin toxicity, which can occur due to overdose, drug interactions, or impaired metabolism. Double vision can impair the client's vision, balance, and coordination, and increase the risk of falls and injuries. The nurse should stop the phenytoin infusion, if applicable, and notify the healthcare provider. The nurse should also check the serum phenytoin level and other vital signs, and prepare to administer an antidote, such as fosphenytoin, if indicated.

Choice C reason: This is not an assessment finding that warrants immediate intervention by the nurse. Puffy, bleeding gums are a common side effect of phenytoin, which can cause gingival hyperplasia, or overgrowth of the gum tissue. Puffy, bleeding gums are not life-threatening, but they can affect the client's oral hygiene and appearance. The nurse should instruct the client to brush and floss the teeth regularly, and to visit a dentist for dental care.

Choice D reason: This is not an assessment finding that warrants immediate intervention by the nurse. Chronic insomnia is not a common or serious side effect of phenytoin, which is an anticonvulsant that can have sedative effects. Chronic insomnia may be caused by other factors, such as stress, pain, or caffeine intake. The nurse should assess the client's sleep pattern and quality, and provide education and counseling on sleep hygiene and relaxation techniques.