Find information about a client below.
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Hematemesis refers to the vomiting of blood and is a severe and potentially life-threatening adverse effect of ibuprofen. Ibuprofen belongs to the class of nonsteroidal anti-inflammatory drugs (NSAIDs), which can cause gastrointestinal bleeding and ulcerations.
Hematemesis indicates significant gastrointestinal irritation or bleeding, and it requires immediate attention from the healthcare provider to assess and manage the client's condition.
Choice B rationale: Nausea is a common side effect of ibuprofen and other NSAIDs. While it is important to monitor and address any adverse effects experienced by the client, nausea alone is not as urgent or critical as hematemesis, which can indicate a more severe complication.
Choice C rationale: Insomnia is not directly related to the use of ibuprofen. While sleep disturbances can occur as a side effect of some medications, it is not the most important finding to report to the healthcare provider in this context.
Choice D rationale: Dizziness can be a side effect of ibuprofen, but it is not the most concerning finding in this situation. Hematemesis, which indicates potential gastrointestinal bleeding, is a more critical symptom that requires immediate attention and reporting to the healthcare provider.
Correct Answer is A
Explanation
Choice A rationale: Heartburn when lying down after dinner can be a symptom of gastroesophageal reflux disease (GERD), which is a common concern in individuals with heart failure. Antacids are commonly used to relieve heartburn by neutralizing stomach acid. For patients with heart failure, it is essential to use low sodium antacids because excess sodium intake can worsen fluid retention and lead to increased heart failure symptoms. Low sodium antacids are specifically designed to minimize the sodium content, making them a suitable choice for individuals with heart failure.
Choice B rationale: Diphenhydramine is an antihistamine commonly used for allergy relief and as a sleep aid due to its sedative effects. However, it is not an appropriate choice for relieving heartburn. Diphenhydramine does not have any direct effect on stomach acid, and it is not indicated for GERD or heartburn relief.
Choice C rationale: Low dose aspirin is primarily used as an antiplatelet agent to reduce the risk of blood clots and is commonly prescribed for patients with certain cardiovascular conditions. However, it is not a suitable medication for relieving heartburn. In fact, aspirin can irritate the stomach lining and worsen symptoms of heartburn and gastric irritation.
Choice D rationale: Acetaminophen is a common over-the-counter pain reliever and fever reducer. While it is useful for managing pain and fever, it does not have any effect on stomach acid and is not indicated for heartburn relief. Acetaminophen is not an appropriate choice for addressing heartburn symptoms.
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