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A nurse is preparing to administer 5 units of regular insulin and 20 units of NPH insulin to a client who has type 1 diabetes mellitus. Which of the following actions should the nurse take first?

Inject 20 units of air into the vial of NPH insulin.

Inject 5 units of air into the vial of regular insulin.

Withdraw 20 units of NPH insulin from the vial.

Withdraw 5 units of regular insulin from the vial.

Answer and Explanation

The Correct Answer is A

Answer: (A) Inject 20 units of air into the vial of NPH insulin.

Rationale:

A) Inject 20 units of air into the vial of NPH insulin:

Injecting air into the vial of NPH insulin is the first step to prevent creating a vacuum, which could make it difficult to withdraw the insulin later. The nurse must inject the corresponding amount of air for the dose needed, ensuring that the insulin can be withdrawn smoothly and accurately without bubbles, which could affect the dose.

B) Inject 5 units of air into the vial of regular insulin:

Injecting air into the regular insulin vial is also necessary before withdrawing the insulin, but it should be done after injecting air into the NPH vial. This sequence ensures that no NPH insulin contaminates the regular insulin vial when the nurse withdraws the doses later.

C) Withdraw 20 units of NPH insulin from the vial:

Withdrawing NPH insulin should be done after air is injected into both vials and after the regular insulin has been drawn up. This sequence prevents the mixing of the two types of insulin and ensures accurate dosing, which is crucial for maintaining the correct blood glucose levels.

D) Withdraw 5 units of regular insulin from the vial:

Withdrawing regular insulin is critical to do before the NPH insulin to prevent contamination of the regular insulin with NPH, which could alter the onset and peak times of the regular insulin. However, it should follow the steps of injecting air into both vials, starting with the NPH vial.

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Correct Answer is A

Explanation

The first action the nurse should plan to perform is to check the client's ability to use the call light. This is essential to ensure that the client can easily communicate with the healthcare team if they need assistance or experience a fall risk situation. By confirming the client's ability to use the call light, the nurse can address any potential communication barriers and ensure that the client has a means to request help promptly.

Explanation for the other options:

b) Document the client's risk in the medical record: While documenting the client's risk in the medical record is important, it is not the first action to be taken. Ensuring the client's immediate safety and ability to request assistance is the priority.

c) Request a referral for physical therapy: Referring the client for physical therapy may be a necessary step to address their impaired mobility and reduce fall risk, but it is not the first action to be performed. Assessing their ability to use the call light takes precedence in order to address immediate safety concerns.

d) Place a gait belt in the client's room: Providing a gait belt is a measure to assist with mobility and falls prevention. However, it should not be the first action. Checking the client's ability to use the call light is more critical to ensure their immediate safety and ability to request help.

A. Sudden dimmed vision B. Cloudy vision C. Intermitent ﬂashes of light D. Pain in the eyes

Correct Answer is B

Explanation

Cloudy vision is a symptom of cataracts. Cataracts occur when the lens of the eye becomes cloudy, causing visual disturbances such as cloudy or blurry vision.The other options are not typical symptoms of cataracts.

a) Sudden dimmed vision may be a symptom of other eye conditions.

c) Intermitent ﬂashes of light (option c) may be a symptom of other eye conditions such as retinal detachment.

d) Pain in the eyes (option d) is not a typical symptom of cataracts.

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A nurse is preparing to administer 5 units of regular insulin and 20 units of NPH insulin to a client who has type 1 diabetes mellitus. Which of the following actions should the nurse take first?

Nursing Test Bank

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