A newly diagnosed diabetic client is 24 hours post-op following abdominal surgery.
The 0700 blood glucose level is 200 mg/dl and the nurse administers 4 units of insulin aspart subcutaneously per the prescribed sliding scale.

When should the nurse first assess the client for signs and symptoms of hypoglycemia?

0800

0730

1130

1000

Answer and Explanation

The Correct Answer is B

Choice A rationale

Hypoglycemia, or low blood sugar, can occur after insulin administration. However, the onset of hypoglycemia is not immediate. Insulin aspart, a rapid-acting insulin, has a peak action time of approximately 1-3 hours after administration. Therefore, assessing the patient for signs and symptoms of hypoglycemia at 0800, one hour after administration, may be too early.

Choice B rationale

Assessing the patient for signs and symptoms of hypoglycemia at 0730, 30 minutes after insulin administration, is too early. The peak action time of insulin aspart is approximately 1-3 hours after administration. Therefore, the nurse should start assessing the patient for signs and symptoms of hypoglycemia closer to the time of peak action.

Choice C rationale

Assessing the patient for signs and symptoms of hypoglycemia at 1130, four and a half hours after insulin administration, may be too late. The peak action time of insulin aspart is approximately 1-3 hours after administration. Therefore, the nurse should start assessing the patient for signs and symptoms of hypoglycemia closer to the time of peak action.

Choice D rationale

Assessing the patient for signs and symptoms of hypoglycemia at 1000, three hours after insulin administration, is within the peak action time of insulin aspart. Therefore, this is the most appropriate time to start assessing the patient for signs and symptoms of hypoglycemia.

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Correct Answer is B

Explanation

Choice A rationale

Increasing the nighttime insulin glargine dose may exacerbate the Somogyi effect, a phenomenon where the blood sugar level drops too low overnight, causing a rebound high blood sugar level in the morning.

Choice B rationale

Consuming a snack at bedtime can help prevent the blood sugar level from dropping too low overnight, thus preventing the Somogyi effect.

Choice C rationale

Checking the morning cortisol level is not directly related to managing the Somogyi effect.

Choice D rationale

Checking the glucose level at 2 a.m. and 8 a.m. can help identify the Somogyi effect, but it does not prevent it.

A. Heparin makes the blood less thick and easier to flow. B. Heparin dissolves the clot and decreases the formation of platelets. C. Heparin does not thin the blood; it prevents new clots from forming. D. Heparin decreases the number of platelets so the blood flows more easily.

Correct Answer is C

Explanation

Choice A rationale

Heparin does not actually thin the blood or make it less thick. Instead, it works by increasing the activity of antithrombin, a protein that inhibits blood clotting. This prevents new clots from forming and existing clots from growing larger.

Choice B rationale

Heparin does not dissolve clots or decrease the formation of platelets. Its primary action is to increase the activity of antithrombin, which in turn inactivates thrombin and factor Xa, two key players in the blood clotting process.

Choice C rationale

This statement is accurate. Heparin does not thin the blood; instead, it prevents new clots from forming and existing clots from growing larger. It does this by increasing the activity of antithrombin, which in turn inactivates thrombin and factor Xa.

Choice D rationale

Heparin does not decrease the number of platelets or make the blood flow more easily. Its primary action is to increase the activity of antithrombin, which in turn inactivates thrombin and factor Xa.

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Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A Type 1 diabetic client with a morning (fasting) glucose of 260 mg/dL has been diagnosed with the Somogyi effect from insulin administration. What intervention should the nurse anticipate including in the plan of care?

Correct Answer is B

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A patient diagnosed with deep vein thrombosis asks the nurse, “How does this blood thinner heparin work?” Which response is most accurate?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Which clinical manifestation should the nurse anticipate as an expected finding for a client diagnosed with deep vein thrombosis (DVT)?

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