A nurse is caring for a patient with diabetes mellitus who is prescribed regular insulin via a sliding scale. After administering the correct dose at 0715, by which of the following times should the nurse ensure the patient receives breakfast?

0720.

0815.

0745.

0730.

Answer and Explanation

The Correct Answer is C

0745.. Regular insulin has an onset of action of 30 to 60 minutes, a peak effect of 2 to 4 hours, and a duration of action of 6 to 8 hours. Therefore, the patient should receive breakfast within 30 minutes of receiving the insulin injection to prevent hypoglycemia.

Choice A. 0720 is incorrect because it is too soon after the injection and the insulin may not have reached its onset of action yet.

Choice B. 0815 is incorrect because it is too late after the injection and the insulin may have reached its peak effect by then, increasing the risk of hypoglycemia.

Choice D. 0730. is incorrect because it is less than 30 minutes after the injection and the insulin may be approaching its peak effect.

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Correct Answer is A

Explanation

initiate one-to-one nursing observation, as this is the most urgent intervention to ensure the safety of the client. The client has a history of depression, substance abuse, anorexia nervosa, and attempted suicide, which indicates that they are at high risk for harm to themselves. One-to-one observation involves an assigned staff member who will be with the client at all times, ensuring their safety and preventing any further self-harm attempts.

Choice B, making a contract with the client for weight gain, is not an appropriate first action as it does not address the client's immediate safety concerns.

Choice C, administering the Hamilton depression scale, may be important to assess the client's depressive symptoms but is not the most urgent priority.

Choice D, reviewing the client's toxicology laboratory report, may be necessary for the overall assessment of the client, but safety comes first.

A. "Disulfiram will prevent my cravings for alcohol." B. "It is important that I take Vitamin C to prevent liver cirrhosis or other liver damage." C. "Withdrawal symptoms should last about 5 to 7 days once they begin." D. "I should expect hand tremors to start less than 24 hours after I stop drinking."

Correct Answer is D

Explanation

The client should expect hand tremors to start less than 24 hours after they stop drinking when reinforcing teaching about alcohol withdrawal with a client who has a history of alcohol use disorder.

Choice A, "Disulfiram will prevent my cravings for alcohol," is incorrect because disulfiram works by creating a very unpleasant reaction when the client drinks alcohol and is not a medication for preventing cravings.

Choice B, "It is important that I take Vitamin C to prevent liver cirrhosis or other liver damage," is incorrect because Vitamin C is not indicated for liver disease related to alcohol use disorder and is not effective in preventing it.

Choice C, "Withdrawal symptoms should last about 5 to 7 days once they begin," is incorrect because withdrawal symptoms can last for several days or even weeks, depending on the severity of the alcohol use disorder.

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A nurse is caring for a patient with diabetes mellitus who is prescribed regular insulin via a sliding scale. After administering the correct dose at 0715, by which of the following times should the nurse ensure the patient receives breakfast?

Nursing Test Bank

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