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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.

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

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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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Using a cushion when sitting may provide comfort, but it does not directly address the client's elevated blood pressure or changes in mental status related to chronic kidney disease (CKD).
B. Weighing every morning is crucial in managing CKD, particularly with elevated blood pressure, as it helps monitor fluid retention, which can indicate worsening kidney function or fluid overload. This intervention is essential for assessing the client's condition and adjusting treatment as needed.
C. Performing range of motion exercises is important for maintaining mobility, especially in an immobile client; however, it does not directly address the pressing issues of elevated blood pressure and altered mental status.
D. Documenting abdominal girth can be important for assessing fluid retention, but it is less immediate than daily weight monitoring for a client with CKD showing significant symptoms.

A. Instruct the UAP in correct removal of contaminated gloves. B. Remind the UAP to remove the gown before removing gloves. C. Advise the UAP to remove the mask after exiting the room. D. Confirm that the UAP has correctly handled the isolation attire.

Correct Answer is D

Explanation

Choice A reason:

Instructing the UAP in the correct removal of contaminated gloves focuses only on one aspect of the PPE removal process. While it is important to remove gloves correctly to prevent contamination, this choice does not address the comprehensive handling of all isolation attire. Proper PPE removal involves multiple steps, including the removal of gowns, masks, and gloves in a specific order to minimize the risk of contamination.

Choice B reason:

Reminding the UAP to remove the gown before removing gloves addresses part of the PPE removal process but not the entire procedure. The correct sequence for removing PPE is crucial to prevent self-contamination. However, this choice does not ensure that all steps are followed correctly. The PN needs to confirm that the UAP understands and correctly performs the entire process, not just one step.

Choice C reason:

Advising the UAP to remove the mask after exiting the room is incorrect because masks should be removed before leaving the isolation room to prevent contamination of the environment outside the isolation area. Droplet precautions require that masks be removed inside the room to contain any infectious agents within the isolation area. This choice could lead to the spread of infection if not followed correctly.

Choice D reason:

Confirming that the UAP has correctly handled the isolation attire ensures that all steps in the PPE removal process are followed correctly. This comprehensive approach helps maintain infection control standards and prevents the spread of infectious agents. By verifying that the UAP has correctly removed and disposed of all PPE, the PN ensures that the UAP adheres to proper protocols, thereby protecting both the healthcare workers and other clients.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is being treated for chronic kidney disease (CKD). On examination, the client has elevated blood pressure (BP) and is exhibiting changes in mental status. Which intervention in the plan of care should the practical nurse (PN) implement?

Correct Answer is B

Explanation

An unlicensed assistive personnel (UAP) removes isolation attire before leaving the room of a client who requires droplet precautions. Which action should the PN take?

Correct Answer is D

Explanation

The practical nurse (PN) believes that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage. Which action should the PN take?

The practical nurse (PN) is assessing an older client with left-sided heart failure (HF). What intervention is most important for the PN to implement?

The practical nurse (PN) is caring for a client newly diagnosed with diabetes mellitus (DM). Which finding is an early sign of hypoglycemia?

The practical nurse (PN) is providing care for a client who is receiving an aminoglycoside to treat a bacterial infection. To assess for signs of ototoxicity, which action should the PN take?

Which intervention is most important for the practical nurse (PN) to implement for a client who is receiving total parenteral nutrition (TPN)?

The practical nurse (PN) observes two unlicensed assistive personnel (UAP) turning an older client who had a hip arthroplasty with prosthesis placement four hours ago. Which observation by the PN indicates that the UAPS needs additional information about the turning procedure?

The practical nurse (PN) is reviewing instructions for the use of pilocarpine ophthalmic drops with a client who has glaucoma. The client replies that the drops should be used to anesthetize the eye if eye pain is experienced. What action should the PN implement?

An older female adult who was admitted to a long-term care facility yesterday is confused about what day of the week it is. Her history does not indicate that she was confused prior to admission. What action should the practical nurse (PN) take?