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
The dose of insulin drawn up in the syringe
The sliding scale insulin lispro order
The sliding scale insulin lispro order
The expiration date on the insulin vial
The insulin concentration
The type of insulin to be administered
Correct Answer : A,C,E,G,H
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 B
Explanation
Choice A rationale: This option is not appropriate as increasing saturated fat intake would exacerbate the oily stool and flatus symptoms caused by orlistat. Orlistat is specifically designed to reduce fat absorption, and increasing fat intake would be counterproductive and may worsen the side effects.
Choice B rationale: Asking a client to describe their dietary intake history is a standard practice in nutritional assessment. It provides a baseline for understanding current eating habits and identifying areas for improvement.
Choice C rationale: Advising a client to stop taking medication should only be done by a qualified healthcare provider who has full knowledge of the client's health history and current medications.
Choice D rationale: While obtaining a stool specimen for evaluation might be relevant in some situations, it is not the priority in this case. The oily stools and flatus are most likely related to the side effects of orlistat and do not typically require stool testing for confirmation. The more immediate action would be to address the symptoms by advising the client to stop taking the medication and contact her healthcare provider for further guidance.
Correct Answer is A
Explanation
A:The primary therapeutic effect of epoetin alfa is to stimulate erythropoiesis, leading to an increase in hemoglobin levels. An increase to 12 g/dL demonstrates that the medication is effectively treating the anemia caused by CKD. Monitoring hemoglobin levels is the most objective and reliable indicator of the medication’s effectiveness.
B: While these subjective improvements can indicate an overall improvement in anemia-related symptoms, they are not the best or most definitive measure of the medication's effectiveness. Objective data, such as hemoglobin levels, provide more concrete evidence.
C: Increased consumption of iron-rich foods is beneficial for clients with anemia, but it is not a direct indicator of the effectiveness of epoetin alfa. Dietary changes can support overall health but do not provide evidence of the medication's impact on hemoglobin levels.
D: Taking concurrent iron therapy is common for clients receiving epoetin alfa, as iron is necessary for the production of red blood cells. However, the absence of adverse effects does not directly indicate the effectiveness of epoetin alfa in increasing hemoglobin levels.
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