A nurse in a clinic is teaching a client who has diabetes mellitus about self-administration of insulin using a prefilled, multidose pen. Which of the following instructions should the nurse include?

Avoid pinching the skin when injecting the needle.

Use pen needles that have a safe-needle protection device attached.

Use the dominant hand to recap the needle before removing it from the pen device.

Remove the needle from the pen device before placing the needle in a sharps container.

Answer and Explanation

The Correct Answer is B

A. Avoid pinching the skin when injecting the needle:

This instruction is not specific to the use of a prefilled, multidose pen for insulin administration. Pinching the skin may be necessary for some injection techniques but is not directly related to the use of a prefilled pen.

B. Use pen needles that have a safe-needle protection device attached.

Using pen needles with a safe-needle protection device attached ensures safe handling and disposal of the needle after use, reducing the risk of accidental needlestick injuries. These devices help prevent accidental needlesticks by covering the needle after use, reducing the risk of transmission of bloodborne pathogens.

C. Use the dominant hand to recap the needle before removing it from the pen device:

Recapping needles is not recommended as it increases the risk of needlestick injuries. Additionally, the use of the dominant hand for recapping is not essential and may not be safe practice.

D. Remove the needle from the pen device before placing the needle in a sharps container:

It's crucial to dispose of needles safely in a sharps container immediately after use without removing the needle from the pen device. Removing the needle before disposal increases the risk of needlestick injuries. The entire pen needle unit, including the needle, should be disposed of intact into an appropriate sharps container to minimize the risk of injury to healthcare workers and others handling the waste.

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Correct Answer is C

Explanation

A. Ensure that the width of the BP cuff is 50% of the client's upper arm circumference:

While using an appropriately sized cuff is crucial for accurate blood pressure measurement, the width of the cuff should be about 40% of the circumference of the upper arm, not 50%. However, adjusting the cuff size is not the most immediate action to take when faced with an elevated blood pressure reading.

B. Reposition the client supine and recheck her BP:

Repositioning the client supine is not necessary for routine blood pressure measurement in a sitting position. Moreover, repositioning the client may not significantly affect the blood pressure reading, especially if the initial reading was obtained correctly.

C. Recheck the client's BP in her other arm for comparison.

When obtaining a blood pressure reading, it's important to confirm the accuracy of the measurement, especially if the reading is elevated. Checking the blood pressure in the other arm allows for comparison and helps identify any significant differences between the arms, which could indicate arterial abnormalities or other issues. This step ensures accuracy and helps in making appropriate clinical decisions.

D. Request that another nurse check the client's BP in 30 min:

Waiting 30 minutes to recheck the blood pressure is not the most appropriate action when faced with an elevated reading. Prompt reevaluation and comparison of blood pressure readings are essential for accurate assessment and timely intervention, especially if the initial reading indicates hypertension.

A. Ensure that the client's bed is in the lowest position. B. Assess skin temperature and color before applying the restraints. C. Attach the client's restraints toe bed rail. D. Pad bony prominences before applying the restraints. E. Secure restraints to allow three fingers to slide under the restraints

Correct Answer is ["A","B","D"]

Explanation

A. Ensure that the client's bed is in the lowest position.

Keeping the bed in the lowest position helps prevent injury if the client tries to get out of bed, especially when restrained.

B. Assess skin temperature and color before applying the restraints.

This action ensures proper circulation and skin integrity while the restraints are in use. It helps prevent skin breakdown and injury.

C. Attach the client's restraints to the bed rail.

Attaching restraints to the bed rail is not considered a best practice as it can increase the risk of injury to the client. Restraints should be secured to the bed frame or another stable part of the bed to minimize the risk of harm.

D. Pad bony prominences before applying the restraints.

Padding bony prominences such as elbows and wrists helps prevent pressure ulcers and discomfort caused by the restraints.

E. Secure restraints to allow three fingers to slide under the restraints.

Restraints should be secured to allow only two fingers to slide under the restraints to ensure they are not too loose or too tight.

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A nurse in a clinic is teaching a client who has diabetes mellitus about self-administration of insulin using a prefilled, multidose pen. Which of the following instructions should the nurse include?

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Correct Answer is C

Explanation

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Correct Answer is ["A","B","D"]

Explanation

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