The nurse is caring for a client receiving regular insulin prescribed per a sliding scale. If a dose of regular insulin is administered at 0730, which additional nursing action is indicated for this client?
Ensure that the client eats breakfast.
Provide a mid-afternoon snack for the client.
Assess the client for hypoglycemia around 1500.
Perform a glucometer reading at 1000.
The Correct Answer is A
A. Ensure that the client eats breakfast: Regular insulin is a fast-acting insulin that typically begins to work within 30 minutes to an hour after administration, peaks around 2-3 hours, and can last for up to 6 hours. Therefore, it is crucial that the client eats a meal, such as breakfast, shortly after the insulin is administered to prevent hypoglycemia.
B. Provide a mid-afternoon snack for the client: While snacks may be necessary depending on the client's overall meal and insulin schedule, it is more critical to ensure the client eats the meal immediately following insulin administration to manage blood glucose levels.
C. Assess the client for hypoglycemia around 1500: While monitoring for hypoglycemia is important, it is more critical to ensure the client eats their meal soon after insulin administration to prevent hypoglycemia in the first place.
D. Perform a glucometer reading at 1000: A glucometer reading at 1000 might be useful for monitoring blood glucose levels but ensuring that the client eats a meal promptly is a more immediate and critical action following insulin administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Until a smaller angle can be restored: Open-angle glaucoma is characterized by a gradual increase in intraocular pressure due to the obstruction of the outflow of aqueous humor, not by a narrow angle. The treatment aims to control eye pressure rather than restore the angle, which is more relevant to acute angle-closure glaucoma.
B. For long-term control of normal eye pressure: Open-angle glaucoma is a chronic condition that requires ongoing management to maintain normal intraocular pressure and prevent damage to the optic nerve. The prescribed eye drops help in managing intraocular pressure over the long term to prevent vision loss.
C. For long-term control of pain and swelling: Open-angle glaucoma typically does not present with pain and swelling. The goal of treatment is to control intraocular pressure rather than address pain or swelling, which are not primary symptoms of this condition.
D. Until the excess pressure is reduced: While initial treatment aims to reduce intraocular pressure, open-angle glaucoma requires ongoing use of medications to maintain normal pressure levels and prevent progression of the disease. Discontinuing the medication after initial pressure reduction can lead to a return of elevated intraocular pressure.
Correct Answer is A
Explanation
A. Limit the intake of foods high in potassium: Spironolactone is a potassium-sparing diuretic, which means it can cause potassium levels to rise. Therefore, the nurse should advise the patient to limit the intake of potassium-rich foods to avoid hyperkalemia.
B. Cover your skin before going outside: This instruction is not specifically related to the use of spironolactone. It is more relevant for medications that cause photosensitivity or skin reactions.
C. Replace salt with a salt substitute: Many salt substitutes contain potassium, which could increase the risk of hyperkalemia when taking spironolactone. Therefore, replacing salt with a potassium-containing salt substitute is not recommended.
D. Monitor skin for excessive bruising: While monitoring for bruising is important, it is more relevant for anticoagulants or medications that affect blood clotting, not specifically for spironolactone.
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