A nurse is planning to administer insulin to a client who has type 1 diabetes mellitus, what action should the nurse perform first?
Administer the client's insulin dose using a tuberculin syringe.
Use a filter needle when withdrawing medication from the multidose vial.
Verify the dose of insulin with another nurse once it is prepared.
Mix the client's long-acting and rapid-acting insulin dose in one syringe.
The Correct Answer is C
A. Administer the client's insulin dose using a tuberculin syringe:
While using an appropriate syringe for insulin administration is important, ensuring the accuracy of the dosage precedes the actual administration. Therefore, verifying the dose takes precedence over selecting the syringe.
B. Use a filter needle when withdrawing medication from the multidose vial:
While using a filter needle can be beneficial to prevent contamination, ensuring the correct dosage is more critical in preventing adverse effects associated with incorrect insulin administration.
C. Verify the dose of insulin with another nurse once it is prepared.
Before administering insulin to a client with type 1 diabetes, it is essential to ensure accuracy in dosage. Verifying the dose with another nurse helps minimize the risk of errors, ensuring the client receives the correct amount of insulin. This step aligns with the principle of double-checking medications for safety, especially in critical situations like insulin administration.
D. Mix the client's long-acting and rapid-acting insulin dose in one syringe:
Mixing different types of insulin in one syringe is not standard practice unless specifically instructed by a healthcare provider. This step should be performed only if explicitly ordered an
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Correct Answer is B
Explanation
A. Swing-through gait:
The swing-through gait is a more advanced gait pattern used by clients with significant lower extremity weakness or paralysis. It involves swinging both crutches forward simultaneously, followed by swinging both legs forward past the crutches. This gait is not appropriate for a client who can only bear weight on one leg.
B. Three-point gait:
The three-point gait is typically used when one lower extremity is completely non-weight-bearing. It involves advancing both crutches and then swinging the affected leg through to meet the crutches. Since the client in this scenario can bear weight on one leg, the three-point gait is the most appropriate choice.
C. Four-point alternating gait
Four-point alternating gait
The four-point alternating gait involves a sequence of movements where each crutch and each leg move alternately. The sequence is as follows:
- Move the right crutch forward(injured side).
- Move the left foot forward(non-injured side).
- Move the left crutch forward(non-injured side).
- Move the right foot forward(injured side). This gait offers stability and control but requires more effort and coordination.
D. Two-point alternating gait:
The two-point alternating gait involves moving one crutch and the opposite lower extremity forward simultaneously, followed by moving the other crutch and the opposite lower extremity forward. This gait pattern is typically used by clients who have good balance and strength in both lower extremities. It may not provide enough stability and support for a client who can only bear weight on one leg.
Correct Answer is D
Explanation
A. Move items in the room away from the client: During a seizure, the client may have uncontrolled movements that could cause them to hit nearby objects and potentially injure themselves. Moving items away from the client helps create a safer environment and reduces the risk of injury from contact with objects.
B. Loosen the client's clothing: Seizures can lead to muscle contractions and movements that might constrict the client's clothing, particularly around the neck or chest area. Loosening the client's clothing helps ensure that their breathing is not restricted during the seizure.
C. Turn the client onto their side: Turning the client onto their side is an important step for airway protection. During a seizure, there is a risk of saliva or vomit obstructing the airway, which can lead to aspiration. Turning the client onto their side helps prevent aspiration by allowing any fluids to drain out safely and maintaining an open airway.
D. Help the client lie on the floor: If the client is seated in a chair during a seizure, it's safer to assist them in lying on the floor. This action prevents the client from falling out of the chair and potentially sustaining injuries from the fall. Once on the floor, the nurse can continue to monitor the client and provide appropriate care and support.
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