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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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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"C"},"G":{"answers":"B"}}

Explanation

Large, liquid stool: Lactulose is prescribed to treat constipation by drawing water into the bowel and promoting a bowel movement. A large, liquid stool indicates that the medication has effectively relieved the client's postoperative constipation.

Abdomen soft and flat: Before receiving lactulose, the client had a distended abdomen. A soft, flat abdomen afterward shows that bowel motility improved and gas or stool buildup has decreased, reflecting therapeutic action.

Blood pressure 120/68 mm Hg: Lactulose does not significantly affect blood pressure. A normal blood pressure reading is a positive finding but is unrelated to the expected outcomes or side effects of lactulose therapy.

Drowsiness: Drowsiness is not an intended or expected effect of lactulose. It may result from opioid use (morphine) rather than the lactulose itself, but since it impacts the client's alertness, it is considered a nontherapeutic side effect here.

Heart rate 62 beats/minute: Lactulose has no direct pharmacologic impact on heart rate. A heart rate of 62 beats per minute is within acceptable limits for many adults and is unrelated to the administration of lactulose.

Pain rating of 2 on a 0 to 10 scale: Pain control relates to the administration of morphine and other analgesics, not to lactulose. Therefore, a lower pain score reflects effective analgesia but is not linked to lactulose therapy.

Cramping: Cramping can occur with lactulose because it increases bowel motility and draws fluid into the intestines. Although mild cramping is expected, it is still classified as a nontherapeutic side effect because it can cause client discomfort.

Correct Answer is []

Explanation

Methemoglobinemia: Methemoglobinemia is characterized by hypoxia symptoms despite normal oxygen saturation readings. However, this condition is very rare in asthma patients and is typically associated with certain medications or chemical exposures, not beta-agonist overuse like albuterol.
Anemia: Anemia could cause dizziness and lightheadedness, but it would not explain palpitations triggered by excessive albuterol use. The acute worsening of symptoms with a background of asthma and heavy beta-agonist use points away from anemia as the primary concern.
Anaphylaxis: Anaphylaxis presents with airway swelling, hypotension, wheezing, and respiratory compromise. Since the client’s oxygen saturation is excellent (99%) and no wheezing or airway edema is noted, anaphylaxis is unlikely in this scenario.
Tachydysrhythmia: Tachydysrhythmia is the most likely diagnosis because overuse of albuterol stimulates beta receptors, leading to increased heart rate, palpitations, dizziness, and lightheadedness. This aligns precisely with the client's reported symptoms and assessment findings.
Administer diphenhydramine: Diphenhydramine is an antihistamine used primarily for allergic reactions and anaphylaxis. There is no evidence of an allergic process in this client; thus, administering diphenhydramine would not address the cardiac symptoms from probable tachydysrhythmia.
Give a dose of albuterol: Administering more albuterol would likely worsen the tachydysrhythmia, as beta-agonists increase heart rate and myocardial oxygen demand. Since the problem stems from albuterol overuse, giving another dose would be inappropriate and harmful.
Take a set of baseline vital signs: Taking a set of baseline vital signs is essential because it provides a foundation for assessing current cardiovascular stability. It would help establish the severity of the tachycardia and guide further intervention strategies.
Place the client on a cardiorespiratory monitor: Placing the client on a cardiorespiratory monitor is critical to continuously assess heart rate, rhythm, and potential arrhythmias. This allows immediate detection of life-threatening patterns such as supraventricular tachycardia or ventricular ectopy.
Draw blood for a complete blood count: Drawing a CBC would help if there was suspicion of anemia or infection, but the clinical picture points primarily toward a cardiac rhythm problem. This diagnostic step would not be immediately necessary based on the current situation.
Methemoglobin level: Monitoring methemoglobin levels would be appropriate if the client had cyanosis or unexplained hypoxia without respiratory distress. Since the oxygen saturation is excellent, checking methemoglobin is not relevant to her current condition.
Iron level: Monitoring iron levels is important in diagnosing chronic anemia, but anemia is not the primary issue here. The focus should remain on cardiovascular monitoring because the immediate symptoms suggest arrhythmia rather than a hematologic cause.
Breath sounds: Although the client currently has no wheezing, regular assessment of breath sounds is necessary to detect any developing bronchospasm or respiratory deterioration, especially given her underlying asthma diagnosis and recent respiratory strain.
Airway edema: Monitoring for airway edema would be essential if anaphylaxis were suspected. Since there are no signs of respiratory distress, stridor, or swelling, airway edema monitoring is less relevant compared to cardiac monitoring in this situation.
Heart rate and rhythm: Heart rate and rhythm must be continuously monitored because the client is exhibiting signs of tachydysrhythmia. Detecting arrhythmias early enables prompt treatment and reduces the risk of serious cardiac complications like syncope or cardiac arrest.

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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

Patient Data Exhibits Mark whether the assessment finding represents a therapeutic result of the lactulose administered, a nontherapeutic side effect, or an unrelated finding. Each row must have one option selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"C"},"G":{"answers":"B"}}

Explanation

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

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.