A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next?
Verify the dosage with another nurse.
Inject 15 units of air into the regular insulin vial.
Withdraw 10 units of NPH insulin.
Place the cap over the needle.
The Correct Answer is B
This step is part of the process when mixing NPH and regular insulin in a single syringe. After injecting air into the NPH insulin vial, you should inject an equal amount of air (in this case, 15 units) into the regular insulin vial to maintain pressure balance. This allows for easy withdrawal of the prescribed doses of each insulin type in the same syringe without causing a vacuum in the vials.
After injecting air into the NPH insulin vial (step 1), the nurse should proceed to inject air into the regular insulin vial (step 2) before withdrawing the insulin doses in the subsequent steps.
Verifying the dosage with another nurse is not necessary in this step, as it is done prior to drawing up the insulin. However, it is good practice to have another nurse double-check the dosage before administration.
Injecting air into the regular insulin vial is not required at this stage. It is only necessary when withdrawing the regular insulin dose.
Placing the cap over the needle should be done after withdrawing the desired dose of insulin and before administering it to the client for safety and to prevent needlestick injuries.
The correct sequence when mixing NPH and regular insulin in a single syringe is as follows:
- Inject air into the NPH insulin vial (in this case, 10 units of air).
- Inject air into the regular insulin vial (in this case, 15 units of air).
- Withdraw the prescribed dose of NPH insulin (10 units) from the NPH vial.
- Withdraw the prescribed dose of regular insulin (15 units) from the regular insulin vial.
So, after injecting air into the NPH insulin vial (step 1), the nurse should proceed to inject air into the regular insulin vial (step 2) before withdrawing the insulin doses in the subsequent steps.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Assessing the client's suicidal intent and the presence of a specific plan for self-harm is crucial in determining the level of immediate risk and the need for intervention. This question directly addresses the client's current state and potential danger.
While all the questions are important in assessing the client's situation, determining the presence of a plan for self-harm takes precedence as it helps evaluate the level of imminent danger and the need for immediate intervention.
The other questions are also important but can be addressed after ensuring the client's safety and appropriate intervention based on the information gathered regarding the plan for self-harm. These questions can provide additional information to further assess the client's support system, history, and current stressors, which can contribute to understanding the context and potential risk factors for the client.
Remember, if the client expresses an immediate plan and intent for self-harm, it is essential to take appropriate steps to ensure their safety, such as involving the appropriate mental health professionals, implementing a safety plan, and providing constant supervision as needed.
Correct Answer is B
Explanation
The plantar Babinski reflex is assessed by stroking the sole of the foot from the heel towards the toes. A normal response is the flexion or curling of the toes. An abnormal response, known as a positive Babinski sign, is the extension and fanning out of the toes, which indicates an upper motor neuron lesion.
"Place your foot in my hand and I will tap the back of your heel": This instruction is more relevant to testing the Achilles tendon reflex, where the nurse taps the back of the heel to elicit a plantarflexion response.
"Sit on the edge of the bed while I tap your knee": This instruction is more relevant to testing the patellar reflex, also known as the knee-jerk reflex. The nurse taps the patellar tendon just below the kneecap to elicit a reflexive contraction of the quadriceps muscle.
"Relax your arm across your chest and I will test your elbow extension": This instruction is more relevant to testing the triceps reflex, where the nurse taps the triceps tendon to elicit a reflexive extension of the elbow.
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