The nurse is administering medications to the client and is monitoring potential adverse effects of medications.

For each body system below, click to specify the assessment findings that could indicate a serious adverse reaction. Each body system may support more than 1 potential assessment finding. To deselect a finding click on the finding again.

Body system	Findings
Head. Eyes. Ears. Nose, and Throat (HEENT)	Yellowing of the eyes Blurred vision Dry eyes
Gastrointestinal	Abdominal pain Weight gain
Hematologic	Increased bruising Increased bleeding tendancies Insomnia
Genitourinary	Darkening of the urine Urinary frequency

A) Can you tell me about the stresses in your life?: While identifying stressors is important in understanding the context of the client’s feelings, the priority in the context of suicidal ideation is to assess the immediacy of danger to the client. Understanding the plan and means for suicide is the first step in evaluating the severity of the situation.

B) "Do you have a plan for harming yourself?": This is the priority question because it directly assesses the immediacy and seriousness of the client’s suicidal ideations. Knowing whether the client has a specific plan allows the nurse to determine the level of risk and take appropriate action, such as ensuring the client is safe and arranging for immediate intervention, including hospitalization if necessary.

C) Do you have someone to discuss your feelings with?: While social support is important, this question does not immediately address the severity of the suicidal ideation. If the client is at high risk, the nurse must first assess the immediate danger posed by the suicidal thoughts and actions before discussing coping strategies or support systems.

D) Has anyone in your family ever died by suicide?: Although a family history of suicide can increase risk, this question is secondary to directly assessing the client's current risk. The focus should first be on evaluating the client’s immediate safety, such as whether they have a plan and the means to harm themselves.

A) Inject 15 units of air into the regular insulin vial:
When drawing insulin from both NPH (a long-acting insulin) and regular insulin (a short-acting insulin), the nurse should first inject air into the NPH insulin vial (which is the intermediate-acting insulin) and then inject air into the regular insulin vial. This technique helps to prevent contamination of the regular insulin vial with NPH insulin. After injecting air into the regular insulin vial, the nurse would then withdraw the regular insulin first and then the NPH insulin to avoid contamination of the regular insulin with the NPH insulin.

B) Withdraw 10 units of NPH insulin:
This action is premature, as the nurse has not yet injected air into the regular insulin vial. The correct sequence involves injecting air into both vials before withdrawing any insulin. Therefore, withdrawing NPH insulin at this stage is not the correct next step.

C) Verify the dosage with another nurse:
While verifying the insulin dosage with another nurse is a good practice for ensuring medication safety, this action is not the immediate next step after injecting air into the NPH insulin vial. The priority is to follow the correct sequence of air injection into the vials before withdrawing the insulin. Verification can occur after the insulin is drawn.

D) Place the cap over the needle:
Placing the cap over the needle is a safety step that is generally performed after withdrawing the insulin and preparing the injection. However, this is not the next step in the process of mixing or drawing insulin, so it is not the correct action to take at this point.