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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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Correct Answer is C

Explanation

A. Reporting any drainage observed around the gastrostomy tube insertion site is important for monitoring potential infection or complications; however, it is not the most immediate concern during a total bed bath.
B. While using plenty of pillows to position the client on the side after bathing is important for comfort and skin integrity, it does not address the safety of the feeding during the bath.
C. Keeping the head of the bed raised while the tube feeding is infusing is the most critical instruction. This position helps prevent aspiration and ensures that the feeding is administered safely while maintaining the client’s airway during the bathing process.
D. Raising the entire bed while bathing the client is helpful for the caregiver's ergonomics but does not take precedence over ensuring the client’s safety regarding the gastrostomy tube feeding.

A. Serum calcium B. Hemoglobin and hematocrit C. White blood cell count (WBC) D. Blood urea nitrogen (BUN) and creatinine

Correct Answer is D

Explanation

This is the correct answer because BUN and creatinine are the most important laboratory values to monitor for nephrotoxicity, which is the damage or injury to the kidneys caused by certain drugs or chemicals.
Nephrotoxicity can impair the kidneys' ability to filter waste products from the blood, resulting in elevated levels of BUN and creatinine. The normal range for BUN is 7 to 20 mg/dL, and for creatinine is 0.6 to 1.2 mg/dL. The practical nurse (PN) should review these values before administering an antibiotic that can cause nephrotoxicity, such as aminoglycosides, cephalosporins, vancomycin, or sulfonamides. The PN should also monitor the client for signs and symptoms of nephrotoxicity, such as decreased urine output, edema, hypertension, fatigue, nausea, and confusion.

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Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is providing instructions to the unlicensed assistive personnel (UAP) preparing to give a total bed bath to an immobile client who has continuous feeding via a gastrostomy tube (GT). Which instruction is most important for the PN to emphasize?

Correct Answer is C

Explanation

Before administering an antibiotic that can cause nephrotoxicity, which laboratory value is most important for the practical nurse (PN) to review?

Correct Answer is D

Explanation

Prior to administering pain medication to an adult postoperative client, what information should the practical nurse (PN) obtain? (Select all that apply.)

The practical nurse (PN) receives shift reports for four newborns in the full-term newborn nursery. Which infant should the PN assess first?

A client with a compound fracture of the left ankle is being discharged with a below-the-knee cast. Which instruction should the practical nurse (PN) provide to the client prior to discharge?

A client who is reaching saturation with medication reports the onset of muscle soreness and fatigue, and the practical nurse (PN) notes that the client's skin is warm to the touch. Which action by the PN is a priority?

The medication aide at a long-term care facility is sick and requests to go home before all medications are administered. Which action should the practical nurse (PN) take in this situation?

The practical nurse (PN) hears an older resident of a long-term care facility shout profanities at an unlicensed assistive personnel (UAP) who shouts back at the resident. Which is the first action the PN should take?

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