A nurse is collecting data from a client who has diabetes mellitus. The client is confused, flushed, and has an acetone odor on his breath. The nurse should anticipate a prescription for which of the following types of insulin to treat the client?

Lantus

NPH

Regular

Lispro

Answer and Explanation

The Correct Answer is C

Choice A Reason: Lantus is not a type of insulin that can treat this client, as it is a long-acting insulin that has no peak effect and lasts for 24 hours.

Choice B Reason: NPH is not a type of insulin that can treat this client, as it is an intermediate-acting insulin that peaks in 6 to 8 hours and lasts for 12 to 18 hours.

Choice C Reason: Regular is a type of insulin that can treat this client, as it is a short-acting insulin that peaks in 2 to 4 hours and lasts for 6 to 8 hours. It can be used to correct high blood glucose levels and treat diabetic ketoacidosis (DKA), which is indicated by confusion, flushing, and acetone breath.

Choice D Reason: Lispro is not a type of insulin that can treat this client, as it is a rapid-acting insulin that peaks in 30 minutes and lasts for 3 to 5 hours. It can be used to cover meals or snacks but not to treat DKA.

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Correct Answer is D

Explanation

Choice A Reason: Administering antispasmodic medications is not the first action that the nurse should perform, as it may not resolve the problem of urinary output or irrigation flow.

Choice B Reason: Notifying the provider is not the first action that the nurse should perform, as it may delay the intervention and worsen the outcome.

Choice C Reason: Offering oral fluids is not the first action that the nurse should perform, as it may increase fluid overload or bladder pressure.

Choice D Reason: Determining the patency of the tubing is the first action that the nurse should perform, as it may identify and correct any obstruction or kinking that prevents urinary output or irrigation flow.

A. Compress the nares. B. Administer decongestant for postnasal drip. C. Tilt the head back. D. Collect the drainage.

Correct Answer is D

Explanation

Choice A Reason: Compressing the nares is not the first action that the nurse should take, as it may increase intracranial pressure and worsen the head injury.

Choice B Reason: Administering decongestant for postnasal drip is not the first action that the nurse should take, as it may mask the signs of cerebrospinal fluid (CSF) leakage and delay diagnosis and treatment.

Choice C Reason: Tilting the head back is not the first action that the nurse should take, as it may cause aspiration of CSF or blood and increase the risk of infection.

Choice D Reason: Collecting the drainage is the first action that the nurse should take, as it helps to identify if the drainage is CSF or nasal secretions, and to monitor the amount and characteristics of the drainage.

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A nurse is collecting data from a client who has diabetes mellitus. The client is confused, flushed, and has an acetone odor on his breath. The nurse should anticipate a prescription for which of the following types of insulin to treat the client?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

What should the nurse do first when a client with a head injury begins to have clear drainage from the nose?

Correct Answer is D

Explanation

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