The client is a 26-year-old female with acute appendicitis. She has a 12-year history of type 1 diabetes and no other significant medical history. The appendectomy was completed without Issue, and the client will be admitted to the surgical floor to recover.
The PN prepares to give 2 units of Insulin lispro.
What should the PN double-check with a second nurse?
Select all that apply.
The sliding scale insulin lispro order
The type of insulin to be administered
The insulin vial for color and clarity
The dose of insulin drawn up in the syringe
The expiration date on the insulin vial
The history and physical with the diabetes diagnosis listed
The insulin concentration
The site for the insulin administration
Correct Answer : C,D,E,G
The PN should double-check the following with a second nurse:
- The dose of insulin drawn up in the syringe: Double-checking the dose of insulin is essential to ensure the correct amount is being administered to the client.
- The insulin vial for color and clarity: Insulin should be clear and free of particles or discoloration. Checking the vial for any abnormalities ensures the integrity and quality of the insulin.
- The expiration date on the insulin vial: Insulin should not be used beyond its expiration date. Verifying the expiration date helps ensure that the insulin is still effective and safe for administration.
- The insulin concentration: Different concentrations of insulin are available, such as
U-100 and U-500. Double-checking the concentration ensures that the correct type of insulin is being administered.
It's important to note that the other options listed are not necessary for double-checking with a second nurse in this context:
- The sliding scale insulin lispro order: Sliding scale insulin is typically used to adjust insulin doses based on blood glucose levels. However, in this case, the given dose of 2 units of insulin lispro may be a specific prescription for the client's diabetes management and not related to the acute appendicitis.
- The type of insulin to be administered: The type of insulin, in this case, is specified as insulin lispro. Confirming the type of insulin is important, but it is not a part of the double-checking process since it is already specified.
- The history and physical with the diabetes diagnosis listed: The client's medical history and diabetes diagnosis are important aspects of their overall care but are not directly related to double-checking the administration of insulin.
- The site for insulin administration: The specific site for insulin administration may depend on the client's individual preference or medical condition, but it is not a part of the double-check process. The double-check is primarily focused on the accuracy of the medication itself.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is the correct answer because it is the best way to assess for signs of ototoxicity, which is a potential adverse effect of aminoglycosides. Ototoxicity is the damage or injury to the inner ear or auditory nerve caused by certain drugs or chemicals. It can result in hearing loss, tinnitus, vertigo, or balance problems. Aminoglycosides are a class of antibiotics that are effective against gram-negative bacteria, but they can also cause ototoxicity by interfering with the function of the hair cells in the cochlea.
The practical nurse (PN) should monitor the client's hearing by asking about any changes in hearing acuity, ringing in the ears, or difficulty understanding speech. The PN should also perform a hearing test using a tuning fork or an audiometer if available. The PN should report any signs of ototoxicity to the healthcare provider and discontinue the aminoglycoside as ordered.
Correct Answer is B
Explanation
To prevent injury in a female client with immune thrombocytopenic purpura (ITP) who is transferred to a long-term care facility for physical rehabilitation, the most important action for the practical nurse to implement is to ensure the client has minimal clutter in the room.
ITP is a condition characterized by a low platelet count, which can result in an increased risk of bleeding and bruising. Clutter in the room can pose a hazard and increase the risk of injury. The client may accidentally bump into objects or trip over items, potentially leading to falls or injuries.
Incorrect:
A- Assessing the client for nerve pain or paralysis is important but may not be directly related to preventing injury in this context. It is essential to address these concerns but not the most important action in preventing injury.
C- Evaluating the client's neurological status after exercising is important for overall assessment and monitoring but does not specifically address the prevention of injury.
D- Monitoring the client's blood cell laboratory values is essential for managing the client's condition but does not directly address preventing injury. It focuses more on the medical management of the client's ITP.
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