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Exhibits

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

The insulin vial for color and clarity

The history and physical with the diabetes diagnosis listed C The dose of insulin drawn up in the syringe

The sliding scale insulin lispro order E The expiration date on the insulin vial

The site for the insulin administration G The insulin concentration H The type of insulin to be administered

The site for the insulin administration

The insulin concentration

The type of insulin to be administered

Answer and Explanation

Correct Answer : A,C,E,G

Choice A rationale: This is essential to ensure that the insulin is not discolored or cloudy, as these changes could indicate a problem with the insulin's stability or effectiveness.
Choice B rationale: While it is essential to have a complete history and physical for proper patient care, double-checking this with another nurse is not necessary in the immediate administration of insulin lispro.
Choice C rationale: Double-checking the dose of insulin in the syringe is crucial to avoid medication errors and ensure that the correct amount is being administered to the patient.
Choice D rationale: The sliding scale order is not mentioned in the information provided, and since it is not part of the immediate insulin administration, it does not need to be double-checked in this context.
Choice E rationale: Checking the expiration date is necessary to ensure that the insulin is still within its usable period. Using expired insulin can lead to reduced potency and potentially ineffective blood sugar control.
Choice F rationale: The information provided in the nurse's notes does not indicate that insulin administration is due at a specific site (e.g., subcutaneous injection). Therefore, there is no need for a second nurse to double-check the site at this moment. However, it's important for the administering nurse to choose the appropriate site following the facility's guidelines and rotate injection sites to prevent lipodystrophy.

Choice G rationale: Different types of insulin come in different concentrations (e.g., U-100, U-200). It's important to confirm that the correct concentration is being used to ensure accurate dosing.
Choice H rationale: The nurse should verify that the insulin to be administered is indeed insulin lispro, as indicated in the medication order. Administering the wrong type of insulin can have significant implications for the patient's blood sugar control.

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Correct Answer is C

Explanation

A. Bedtime is the best time to take the tablet.While taking medication at bedtime can sometimes be convenient, it is not necessarily the best time for iron absorption. Iron is best absorbed on an empty stomach, and bedtime might not always align with this condition.

B. Crush the tablets and mix with pudding.Crushing enteric-coated tablets is not recommended because it destroys the coating designed to protect the stomach lining from irritation and to ensure the iron is released in the intestine where it is best absorbed.

C. Wait 2 hours after meals to take the tablet.This is the correct answer because iron is best absorbed on an empty stomach, typically one hour before or two hours after meals. Food can interfere with the absorption of iron, so waiting ensures better efficacy of the supplement.

D. Take the tablet with a daily multivitamin.Taking iron with a multivitamin can be problematic because certain minerals in multivitamins, such as calcium, can inhibit iron absorption. It is better to take iron supplements separately to maximize absorption.

A. Administer the dose and monitor the client's BP regularly. B. Withhold the scheduled dose and notify the healthcare provider. C. Apply a telemetry monitor before administering the dose. D. Assess for orthostatic hypotension before administering the dose.

Correct Answer is B

Explanation

Choice A rationale: Administering the dose of labetalol without further assessment may not be appropriate in this situation. The client's heart rate is 48 beats/minute, which is considered bradycardia (heart rate below the normal range of 60-100 beats/minute). Bradycardia can be a potential adverse effect of labetalol, a beta-blocker. Moreover, the client's blood pressure is elevated at 150/90 mm Hg, indicating that the hypertension is not well controlled. Administering the dose without addressing the bradycardia or elevated blood pressure could potentially exacerbate these issues.

Choice B rationale: Withholding the scheduled dose of labetalol is the most appropriate action in this scenario. The client's heart rate of 48 beats/minute is considered bradycardia, which may be a side effect of labetalol or indicative of an underlying issue. Additionally, the client's blood

pressure is elevated, indicating inadequate control of hypertension. Bradycardia can reduce cardiac output and may lead to further complications. Notifying the healthcare provider is essential to obtain further instructions and address the client's bradycardia and hypertension before administering the medication.

Choice C rationale: While telemetry monitoring is appropriate for clients with certain cardiac conditions or when changes in heart rate need close observation, it may not be the most urgent action in this situation. The client's bradycardia and elevated blood pressure are concerning and require immediate attention. Telemetry monitoring may be considered later, but it does not address the immediate need to withhold the medication and seek guidance from the healthcare provider.

Choice D rationale: Orthostatic hypotension refers to a drop in blood pressure when changing positions, such as from lying down to standing up. While orthostatic hypotension is a valid concern for clients taking antihypertensive medications, it is not the primary issue in this scenario. The client's heart rate is 48 beats/minute, indicating bradycardia and the blood pressure is elevated at 150/90 mm Hg, suggesting uncontrolled hypertension. These are the main concerns that require immediate attention and further assessment before administering the labetalol dose.

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Find information about a client below. Exhibits What should the nurse double-check with a second nurse? Select all that apply.

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Naxlex Comprehensive Predictor Exams

An older adult with iron deficiency anemia is being discharged with a prescription for ferrous sulfate enteric-coated tablets. To promote best absorption of the medication, which information should the nurse include in the discharge instructions?

Correct Answer is C

Explanation

The nurse prepares to administer a scheduled dose of labetalol by mouth to a client with hypertension. The client's vital signs are temperature 99° F (37.2° C), heart rate 48 beats/minute, respirations 16 breaths/minute, and blood pressure (B/P) 150/90 mm Hg. Which action should the nurse take?

Correct Answer is B

Explanation

A client with chemotherapy induced nausea receives a prescription for metoclopramide. Which adverse effect is most important for the nurse to report?

A nurse is assessing a client's ability to swallow. Which of the following, when selected by the nurse, indicates an understanding of the cranial nerve that tests the ability to swallow?

The healthcare provider prescribes the antibiotic tetracycline HCI for an adult client that arrived at an outpatient clinic. Which instruction should the nurse include in the teaching plan for this client?

The nurse is preparing a discharge teaching plan for a client who is taking ciprofloxacin hydrochloride tablets, which were prescribed because of a suspected anthrax exposure. Which instruction(s) should be included in the teaching plan? (Select all that apply.)

A male client with a history of heart failure (HF) complains of heartburn when he lies down after dinner. The home health nurse should encourage the client to talk to the healthcare provider about using which over-the-counter medication to relieve this problem?

The nurse reviews the lab values. Exhibits What questions can the nurse ask the client based on the lab results? Select all that apply.

Exhibits The provider would like the client to continue with the captopril dose and restart the spironolactone. The provider wants the client to return to the clinic in 6 weeks with lab work done. What 2 labs would be most appropriate for this client to complete on their return visit?

Find information about a client below.

Exhibits

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