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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Leave the patch in place and administer a PRN dose of sublingual nitroglycerin: It is appropriate to administer a PRN dose of sublingual nitroglycerin for immediate relief of acute angina while leaving the transdermal patch in place. The sublingual nitroglycerin acts quickly to relieve chest pain, while the transdermal patch provides a longer, more sustained effect.
B. Reassure the client that the patch will begin to take effect within a few minutes: The transdermal patch generally takes 30 to 60 minutes to reach therapeutic levels, which is not suitable for immediate relief of acute chest pain. Therefore, reassurance alone may not address the current symptoms effectively.
C. Withhold further doses of nitroglycerin until contacting the healthcare provider: Withholding further doses of nitroglycerin without assessing the situation can delay appropriate relief of chest pain. Immediate intervention is necessary, and it is appropriate to use sublingual nitroglycerin as needed.

D. Obtain another transdermal patch and position it on the patient's left upper chest: Applying an additional transdermal patch is not necessary and could lead to excessive nitroglycerin exposure. The current patch should be left in place, and sublingual nitroglycerin can be used for acute symptoms.

A. Administer the medication B. Notify the healthcare provider. C. Hold the medication until the meal trays arrive. D. Obtain another finger tick blood glucose level.

Correct Answer is C

Explanation

A. Administer the medication: Acarbose is an alpha-glucosidase inhibitor that should be taken with the first bite of a meal to effectively manage postprandial blood glucose levels. Administering it before the meal is inappropriate as it can lead to inadequate glucose control.
B. Notify the healthcare provider: While notifying the healthcare provider might be necessary if there are significant issues, it is not the immediate action needed in this situation. The priority is to manage the timing of the medication relative to the meal.
C. Hold the medication until the meal trays arrive: Acarbose should be taken with food to work effectively in controlling blood glucose levels after meals. If the meal is delayed, the medication should be held until the meal is ready to ensure proper administration.
D. Obtain another finger stick blood glucose level: Rechecking the blood glucose level does not address the issue of the timing of the acarbose administration. The focus should be on ensuring the medication is taken with the meal.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of angina reports the onset of chest pain. The nurse determines that the heart rate is 104 beats/minute and the blood pressure is 138/86 mm Hg. A transdermal nitroglycerin patch was applied 30 minutes ago to the right upper chest. Which action should the nurse take?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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