History and Physical
The client is a 26-year-old female with acute appendicitis. She has a 12-year history of type 1 diabetes and no other significant medical histor The appendectomy was completed without issue, and the client will be admitted to the surgical floor to recover.
For each nursing action below, click to specify if the action is indicated, contraindicated or non-essential.
Verify that the client can count carbohydrates
Restart the IV fluids until the tray arrives
Give insulin lispro 4 units
Give insulin glargine 12 units
Mix the insulin lispro and insulin glargine in one syringe
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"}}
Choice A rationale: Indicated. This is important for a client with type 1 diabetes, as counting carbohydrates helps in calculating the appropriate insulin dose and maintaining glycemic control.
Choice B rationale: Non-essential. The client is already admitted to the surgical floor and does not require restarting the IV fluids unless there is a specific medical indication.
Choice C rationale: Contraindicated. Insulin doses should be prescribed by a healthcare provider based on the patient's blood glucose levels and individual insulin requirements. The nurse should follow the prescribed insulin orders and not administer insulin without an order.
Choice D rationale: Indicated. Insulin glargine is a long-acting basal insulin used to provide a steady background insulin level throughout the day. The nurse should administer the prescribed insulin glargine dose as ordered.
Choice E rationale: Contraindicated. Insulin lispro is a rapid-acting insulin, and insulin glargine is a long-acting insulin. Mixing different types of insulin in one syringe can alter their pharmacokinetics and lead to inconsistent blood glucose control. Insulin lispro and insulin glargine should be administered separately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E"]
No explanation
Correct Answer is D
Explanation
Choice A rationale: This instruction is not directly related to spironolactone use or hyperaldosteronism. Excessive bruising may be relevant in some situations but not specifically for this scenario.
Choice B rationale: While heart failure patients are often advised to reduce their sodium intake, the use of a salt substitute (potassium-based) would be contraindicated in this case due to the risk of hyperkalemia.
Choice C rationale: This instruction is not directly related to spironolactone use or
hyperaldosteronism. It may be relevant for sun protection, but it is not a priority in this context.
Choice D rationale: Spironolactone is a potassium-sparing diuretic, which means it helps the body retain potassium while excreting sodium and water. Since the client has heart failure (HF), there is a risk of hyperkalemia (high potassium levels) associated with spironolactone use. To prevent this, the nurse should instruct the client to limit their intake of high-potassium foods, such as bananas, oranges, tomatoes, spinach, and other potassium-rich foods.
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