A nurse is reinforcing teaching with an adolescent about self-administration of insulin. Which of the following instructions should the nurse include?
"You should chill your medication before administration”
"You should rotate sites when administering the medication."
"You should administer your medication at a 45-degree angle”
"You should administer your insulin into a muscle.”
The Correct Answer is B
A. "You should chill your medication before administration." Insulin should not be chilled before administration. It should be stored in a cool place, but administering insulin directly from the refrigerator can cause discomfort.
B. "You should rotate sites when administering the medication." Rotating injection sites helps prevent tissue damage and the formation of lumps or scar tissue. It is recommended to rotate sites within the same area (e.g., abdomen, thigh, etc.) to ensure absorption and prevent complications.
C. "You should administer your medication at a 45-degree angle." Insulin should generally be administered at a 90-degree angle for subcutaneous injection, not a 45-degree angle. A 45-degree angle may be appropriate.
D. "You should administer your insulin into a muscle." Insulin should be administered subcutaneously (into the fat layer just under the skin), not into the muscle. Injecting insulin into a muscle can alter its absorption rate and may cause irritation or pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Temperature: A temperature of 38.6°C (101.5°F) is elevated, but fever is a common symptom of bacterial pneumonia. It is important to monitor, but it is not the most critical finding in this case.
B. Skin condition: Hives and flushing could be signs of an allergic reaction to medication, but this is not immediately life-threatening. The nurse should report it, but the priority in this case is the oxygen saturation, which reflects the patient's respiratory status.
C. Oxygen saturation: Oxygen saturation of 93% is below the typical threshold of 95-100% and indicates mild hypoxemia. In a patient with bacterial pneumonia, low oxygen saturation signify worsening respiratory function. This requires immediate attention and reporting.
D. Lung sounds: Coarse crackles in the right lower lobe are expected in pneumonia due to lung consolidation. While it is important to monitor lung sounds, the priority is addressing the oxygen saturation level, which is directly related to the patient's ability to breathe effectively.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Rationale for Correct Choices:
- Administer anticonvulsant: Since the adolescent is having symptoms that precede a seizure (blurred vision), administering an anticonvulsant as prescribed can help prevent or reduce seizure activity.
- Place the client lying on the side: Lying on the side ensures an open airway and reduces the risk of aspiration during a seizure. This position also allows secretions to drain safely.
Rationale for Incorrect Choices:
- Place a tongue blade in the client’s mouth: A tongue blade can cause injury to the teeth or mouth and increase choking risk. The proper approach is to place the client on their side and avoid putting objects in their mouth.
- Restrict movement in the extremities: Restricting movement could cause injury. The focus should be on safety by allowing the seizure to occur without interference while monitoring vital signs and activity.
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