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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.

A.

The sliding scale insulin lispro order

B.

The type of insulin to be administered

C.

The insulin vial for color and clarity

D.

The dose of insulin drawn up in the syringe

E.

The expiration date on the insulin vial

F.

The history and physical with the diabetes diagnosis listed

G.

The insulin concentration

H.

The site for the insulin administration

Answer and Explanation

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.


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Related Questions

Correct Answer is D

Explanation

This is the action that the PN should implement for a male client who has just been told he has cancer and asks to be left alone. Leaving the room after offering to return later respects the client's autonomy and privacy, while also showing empathy and availability. The client may need some time and space to process the diagnosis and cope with his emotions. The PN should not force the client to talk or stay with him if he does not want to, but should also not abandon him or ignore his needs.

Correct Answer is D

Explanation

Hives (also known as urticaria) are raised, red, itchy welts on the skin that can be caused by an allergic reaction to medication, including antibiotics. It is essential for the PN to recognize this potentially severe allergic reaction and take immediate action.

Immediate action steps include:

  1. Stop the infusion of the intravenous antibiotic immediately.
  2. Notify the healthcare provider and report the allergic reaction.
  3. Assess the client's airway, breathing, and circulation to ensure there are no signs of respiratory distress or anaphylaxis.
  4. Administer prescribed emergency medications if needed (e.g., epinephrine, antihistamines).
  5. Monitor the client closely for any further signs of an allergic reaction or anaphylaxis.

The other assessment findings mentioned are also important to address, but they do not require immediate action:

A- Dry mouth with thirst: This may indicate dehydration, which should be addressed by encouraging the client to drink fluids, but it does not pose an immediate threat to the client's safety.

B- Warm skin with elastic turgor: This suggests that the client is adequately hydrated, and the skin's elasticity is normal, which is a positive finding.

C- Low-grade fever with diaphoresis: A low-grade fever indicates a mild elevation in temperature, and diaphoresis (sweating) may be the body's response to regulate temperature. The PN should monitor the client's temperature and assess for other signs of infection, but this finding does not require immediate action

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