A nurse is preparing regular and NPH insulin in the same syringe for a client who has diabetes mellitus.
Which of the following actions should the nurse take?

Choice A rationale

Using clean technique for invasive procedures in a neutropenic client is insufficient. Neutropenia is a severe reduction in neutrophils, a key component of the immune system, leaving the client highly susceptible to infection. Aseptic or sterile technique, rather than clean technique, is necessary for all invasive procedures to prevent the introduction of pathogens. This includes strict hand hygiene, sterile gloves, and sterile fields to minimize infection risk.

Choice B rationale

Allowing healthy children to visit is a dangerous practice for a neutropenic client. Children, even those appearing healthy, can carry and transmit pathogens like viruses and bacteria that their developing immune systems can easily fight off. In a client with neutropenia, however, these common microorganisms can cause severe, life-threatening infections due to the lack of an adequate immune response. Therefore, visitors must be carefully screened.

Choice C rationale

Cleaning the client's room every 2 days is an inadequate frequency for a neutropenic client. An environment with reduced pathogen exposure is crucial for these immunocompromised clients. The room should be cleaned daily to minimize the accumulation of dust, dirt, and microorganisms. All surfaces, including floors, tables, and equipment, must be disinfected to reduce the risk of nosocomial infections and maintain a sterile environment.

Choice D rationale

Neutropenia impairs the body's ability to mount a fever response to infection. Therefore, a low-grade temperature elevation may be the only sign of a serious infection. Monitoring the client's temperature frequently, typically every 4 hours, is a critical nursing intervention. Early detection of a fever, even a slight one, allows for prompt initiation of antibiotics and other treatments, significantly improving the client's prognosis and preventing a potential septic shock. *.

Choice A rationale

Ketonuria, the presence of ketones in the urine, is typically associated with hyperglycemia and diabetic ketoacidosis. When glucose levels are high and cells can't use it for energy, the body starts breaking down fats, producing ketones as a byproduct. A blood glucose reading of 64 mg/dL is low and indicates hypoglycemia, not hyperglycemia.

Choice B rationale

Warm skin is a sign of vasodilation, often associated with a fever or an inflammatory response. In the context of hypoglycemia, the sympathetic nervous system is activated, leading to vasoconstriction, which would typically cause the skin to feel cool and clammy, not warm.

Choice C rationale

Nervousness is a common symptom of hypoglycemia. When blood glucose levels drop, the body releases counterregulatory hormones like epinephrine and norepinephrine from the adrenal glands. This sympathetic nervous system activation causes symptoms such as nervousness, anxiety, palpitations, and tremors as the body attempts to raise blood sugar.

Choice D rationale

Tachypnea, or rapid breathing, is a clinical finding associated with metabolic acidosis, such as diabetic ketoacidosis (DKA). In DKA, the body tries to compensate for the high acid load by increasing the respiratory rate to blow off carbon dioxide. It is not a typical symptom of hypoglycemia, which is indicated by a reading of 64 mg/dL. .