A nurse is providing teaching for a client who has diabetes mellitus about the self-administration of insulin. The client has prescriptions for regular and NPH insulins. Which of the following statements by the client indicates an understanding of the teaching?
"I will draw the regular insulin into the syringe first."
"I will store prefilled syringes in the refrigerator with the needle pointed upward."
"I will gently roll the NPH vial between my hands before drawing up the insulin."
"I will insert the needle at a 90-degree angle."
The Correct Answer is A
Choice A reason: Drawing the regular insulin into the syringe first is correct. When mixing two types of insulin, the clear (regular) insulin should be drawn up before the cloudy (NPH) insulin to prevent contamination.
Choice B reason: Storing prefilled syringes with the needle pointed upward can cause air bubbles to move into the insulin, which can alter the dose when injected. The needle should be pointed downward.
Choice C reason: Shaking the NPH vial vigorously is not recommended as it can create air bubbles and affect the insulin dose. Instead, the vial should be gently rolled between the hands to mix the insulin.
Choice D reason: Inserting the needle at a 15-degree angle is incorrect for subcutaneous injections. A 90-degree angle is typically used unless the patient is very thin, in which case a 45-degree angle may be used.
Nursing Test Bank
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Related Questions
Correct Answer is ["8.3"]
Explanation
Step 1: Total volume = 1000 mL (which is 1 liter)
Step 2: Total time = 2 hours. But since the infusion pump rate is typically set in mL per minute, we need to convert this to minutes. There are 60 minutes in an hour, so 2 hours is 2 × 60 = 120 minutes.
Step 3: Now we can calculate the rate. The rate is the total volume divided by the total time. So, the rate = 1000 mL ÷ 120 minutes.
Calculating the above gives us the rate at which the nurse will set the infusion pump. Let's calculate it:
Step 4: Rate = 1000 mL ÷ 120 minutes = 8.33 mL/minute.
So, the nurse will set the infusion pump at a rate of approximately 8.33 mL per minute. If rounding is required, this can be rounded to 8.3 mL per minute.
Correct Answer is D
Explanation
Choice A reason: Instructing the client to expect tingling in their extremities is not a standard post-lumbar puncture care instruction. Tingling may be a sign of nerve irritation or damage, which is not an expected outcome and should be reported if it occurs.
Choice B reason: Measuring blood glucose every 2 hours is not related to post-lumbar puncture care unless the client has a specific condition that requires such monitoring. Post-lumbar puncture care focuses on preventing complications such as headaches and monitoring for signs of infection or bleeding.
Choice C reason: Limiting the client's fluid intake is not advised following a lumbar puncture. In fact, increasing fluid intake can help prevent the occurrence of post-lumbar puncture headaches, which are a common complication. Adequate hydration helps replenish cerebrospinal fluid and reduce headache severity.
Choice D reason: Instructing the client to lie flat is the correct action. After a lumbar puncture, it is recommended that the client lies flat for several hours to prevent the leakage of cerebrospinal fluid from the puncture site, which can lead to a spinal headache. Lying flat helps maintain normal cerebrospinal fluid pressure and reduces the risk of headache.
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