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Patient Data

Exhibits

The nurse prepares to give 2 units of insulin lispro.

Which should the nurse double check with a second nurse? Select all that apply.

The site for the insulin administration

The insulin vial for color and clarity

The dose of insulin drawn up in the syringe

The insulin concentration

The expiration date on the insulin vial

The sliding scale insulin lispro prescription

The history and physical with the diabetes diagnosis listed

The type of insulin to be administered

Answer and Explanation

Correct Answer : C,D,F,H

A. The site for the insulin administration: While site selection is important for absorption consistency, double-checking the injection site with another nurse is not required under insulin safety protocols. It is an individual nursing responsibility.

B. The insulin vial for color and clarity: Although inspecting insulin for proper color and clarity is critical, it does not formally require double-checking with another nurse. It is part of standard administration checks performed by the individual nurse.

C. The dose of insulin drawn up in the syringe: Double-checking the correct dose with another nurse is essential to prevent dosing errors. Insulin is considered a high-alert medication, and the dose must be verified to ensure client safety.

D. The insulin concentration: Insulin comes in different concentrations (e.g., U-100, U-500). Verifying the concentration with a second nurse is vital to avoid giving the wrong dose based on an incorrect strength.

E. The expiration date on the insulin vial: Checking the expiration date is necessary, but it does not formally require a second nurse verification. It is part of safe medication administration practices.

F. The sliding scale insulin lispro prescription: Ensuring the sliding scale prescription is accurately followed is crucial. Double-checking that the blood glucose reading matches the correct insulin dose according to the sliding scale prevents errors.

G. The history and physical with the diabetes diagnosis listed: Confirming a diagnosis is useful background information but is not necessary to double-check before insulin administration. The medication order itself already assumes the clinical need.

H. The type of insulin to be administered: Verifying that the correct type of insulin (e.g., insulin lispro for rapid-acting) is being used is mandatory. A second nurse must confirm that the right insulin type matches the order to avoid administration mistakes.

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Correct Answer is C

Explanation

A. Compress the client's nares: Compressing the nares is a technique used for nasal medication administration or controlling nosebleeds, not for sublingual or oral spray forms of nitroglycerin. This action is unrelated to nitroglycerin use for angina.

B. Observe for facial flushing: Facial flushing is a common side effect of nitroglycerin due to vasodilation. While it should be noted during monitoring, it is not the immediate next action after administration when addressing angina symptoms.

C. Advise the client to rest: Resting after nitroglycerin administration reduces myocardial oxygen demand, helping to relieve anginal pain more effectively. It also helps prevent hypotension and dizziness, which are common side effects of the medication.

D. Elevate the client's feet: Elevating the feet is typically done if hypotension occurs. It is not a standard next step immediately after giving nitroglycerin unless the client shows symptoms like syncope or significant blood pressure drops.

A. Review most recent coagulation laboratory values. B. Report findings to healthcare provider (HCP). C. Complete a medication variance report. D. Obtain a soft bristle toothbrush for client. E. Provide a PRN nonsteroidal antiinflammatory drug (NSAID) for gum discomfort.

Correct Answer is ["A","B","D"]

Explanation

A. Review most recent coagulation laboratory values: Checking coagulation studies like INR, PT, or aPTT is essential to assess the client's bleeding risk and determine if the anticoagulant effect is too strong, helping guide further medical management.

B. Report findings to healthcare provider (HCP): Bleeding gums and easy bruising are signs of excessive anticoagulation, which could become life-threatening. Promptly notifying the HCP allows for immediate evaluation and possible adjustment of the medication.

C. Complete a medication variance report: A medication variance report is appropriate when there is an error in prescribing, dispensing, or administering. Since this appears to be a medication side effect rather than an error, a variance report is not needed at this stage.

D. Obtain a soft bristle toothbrush for client: Using a soft toothbrush minimizes trauma to the gums, helping to reduce the risk of further bleeding while still maintaining oral hygiene, an important supportive intervention for clients on anticoagulants.

E. Provide a PRN nonsteroidal antiinflammatory drug (NSAID) for gum discomfort: NSAIDs increase the risk of bleeding and should be avoided in clients taking anticoagulants. Treating discomfort with NSAIDs could worsen bleeding complications rather than relieve them safely.

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Patient Data Exhibits The nurse prepares to give 2 units of insulin lispro. Which should the nurse double check with a second nurse? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After administering nitroglycerin spray to a client experiencing angina, which action should the nurse implement next?

Correct Answer is C

Explanation

After receiving the third dose of a new oral anticoagulant prescription, an older adult client develops bleeding and tender gums and has many new bruises. Which action(s) should the nurse implement? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

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Patient Data

Exhibits

The nurse prepares to give 2 units of insulin lispro.

Which should the nurse double check with a second nurse? Select all that apply.