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 A
Explanation
The action the practical nurse (PN) should take in this situation is to administer a prescribed PRN (as needed) dose of analgesic.
Severe burning pain along the right side of the trunk is a common symptom of herpes zoster (shingles). Managing the client's pain is an important aspect of care to provide comfort and promote healing. Administering a prescribed PRN dose of analgesic will help alleviate the client's pain and improve their overall well-being. It is crucial to follow the client's prescribed medication regimen and provide pain relief as needed.
The other options are not the most appropriate actions in this situation:
B. Notifying the nursing supervisor of uncontrolled pain may be necessary if the client's pain persists despite appropriate interventions. However, the first step should be to administer an analgesic to address the immediate pain.
C. Giving the next prescribed dose of antiviral medication is important in the treatment of herpes zoster, but it does not directly address the client's current severe burning pain. Analgesics are specifically designed to alleviate pain symptoms.
D. Obtaining an oxygen tank for home administration is not indicated for the management of pain associated with herpes zoster. Oxygen therapy is typically used for respiratory or circulatory conditions and would not be the appropriate intervention for the client's symptom of severe burning pain.
Correct Answer is B
Explanation
Hypoglycemia occurs when blood glucose levels drop below normal levels. It is commonly associated with diabetes mellitus and can result from various factors such as excessive insulin or oral hypoglycemic medication, delayed or missed meals, increased physical activity, or alcohol consumption.
Tremors, or shaking hands, are one of the early signs of hypoglycemia. They can occur due to the brain's response to low blood glucose levels. Other early signs of hypoglycemia may include sweating, palpitations, anxiety, hunger, and weakness.
A. Polyuria, or excessive urination, is not typically associated with hypoglycemia. It is more commonly seen in conditions such as hyperglycemia or diabetes insipidus.
C. Bradycardia, or a slow heart rate, is not a characteristic sign of hypoglycemia. It can occur in some cases of severe hypoglycemia, but it is not an early sign.
D. Difficulty swallowing is not directly related to hypoglycemia. It may be caused by other factors such as neurological or muscular conditions, esophageal disorders, or structural abnormalities in the throat or esophagus.
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