The nurse is preparing to administer Regular insulin to a client with a blood glucose of 265. What action should the nurse take to determine the correct dose?

Review the patient’s previous blood glucose levels

No review is necessary before administering insulin

Review the Regular insulin sliding scale for administration in the patient’s electronic medical record

Review the patient’s previous insulin administration doses

Answer and Explanation

The Correct Answer is C

Choice A reason: This is incorrect. Reviewing the patient’s previous blood glucose levels may not be helpful in determining the correct dose of insulin, as the blood glucose level can fluctuate depending on various factors, such as food intake, activity, stress, and illness. The previous blood glucose levels may not reflect the current insulin needs of the patient¹.

Choice B reason: This is incorrect. No review is not an option before administering insulin, as insulin is a highalert medication that can cause serious harm if given incorrectly. The nurse should always check the patient’s blood glucose level, the insulin order, the insulin type, the insulin dose, the insulin expiration date, and the insulin injection site before giving insulin.

Choice C reason: This is correct. Reviewing the Regular insulin sliding scale for administration in the patient’s electronic medical record is the best action to determine the correct dose of insulin. A sliding scale is a chart of insulin dosages based on blood glucose level and mealtime. It is used to adjust the insulin dose according to the patient’s blood glucose level and insulin sensitivity. The nurse should follow the sliding scale protocol and verify the insulin dose with another nurse before administering it.

Choice D reason: This is incorrect. Reviewing the patient’s previous insulin administration doses may not be helpful in determining the correct dose of insulin, as the insulin dose may vary depending on the patient’s blood glucose level and insulin sensitivity. The previous insulin doses may not reflect the current insulin needs of the patient¹.

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Correct Answer is D

Explanation

Choice A reason: Administering half of the scheduled dose of Colace is not the correct action for the nurse who is caring for a patient who had two loose stools during the night shift. Colace is the brand name of docusate, which is a stool softener that works by increasing the amount of water and fat in the stool, making it easier to pass. Colace is used to treat and prevent constipation, which is a condition of infrequent or hard bowel movements. Colace is not indicated for diarrhea, which is a condition of frequent and loose bowel movements. Administering half of the scheduled dose of Colace may not be enough to prevent constipation, and it may also worsen diarrhea by adding more water and fat to the stool.

Choice B reason: Administering the scheduled dose of Colace is not the correct action for the nurse who is caring for a patient who had two loose stools during the night shift. Colace is the brand name of docusate, which is a stool softener that works by increasing the amount of water and fat in the stool, making it easier to pass. Colace is used to treat and prevent constipation, which is a condition of infrequent or hard bowel movements. Colace is not indicated for diarrhea, which is a condition of frequent and loose bowel movements. Administering the scheduled dose of Colace may not be necessary to prevent constipation, and it may also worsen diarrhea by adding more water and fat to the stool.

Choice C reason: Inserting a rectal tube to prevent excoriation is not the correct action for the nurse who is caring for a patient who had two loose stools during the night shift. A rectal tube is a device that is inserted into the rectum and connected to a drainage bag, which collects the stool and prevents leakage and skin irritation. A rectal tube is used for patients who have fecal incontinence, which is the inability to control bowel movements. A rectal tube is not indicated for patients who have diarrhea, which is a condition of frequent and loose bowel movements. Inserting a rectal tube may not be effective to prevent excoriation, and it may also cause complications such as infection, bleeding, or perforation.

Choice D reason: Holding the scheduled dose of Colace and notifying the ordering physician is the correct action for the nurse who is caring for a patient who had two loose stools during the night shift. Colace is the brand name of docusate, which is a stool softener that works by increasing the amount of water and fat in the stool, making it easier to pass. Colace is used to treat and prevent constipation, which is a condition of infrequent or hard bowel movements. Colace is not indicated for diarrhea, which is a condition of frequent and loose bowel movements. Holding the scheduled dose of Colace may be appropriate to avoid further diarrhea, and notifying the ordering physician may be necessary to determine the cause and the treatment of diarrhea

A. dextromethorphan (Robitussin) B. fluticasone (Flonase) C. pseudoephedrine (Sudafed) D. guaifenesin (Mucinex)

Correct Answer is D

Explanation

Choice A reason: Dextromethorphan (Robitussin) is not the correct medication for a patient with a productive cough. Dextromethorphan is a cough suppressant that works by acting on the brain to reduce the cough reflex. Dextromethorphan is used for a dry, nonproductive cough that is caused by irritation or inflammation. Dextromethorphan is not effective for a productive cough that produces mucus, and it may even be harmful by preventing the clearance of secretions from the lungs.

Choice B reason: Fluticasone (Flonase) is not the correct medication for a patient with a productive cough. Fluticasone is a corticosteroid that works by reducing inflammation and swelling in the nasal passages. Fluticasone is used for allergic rhinitis, which is a condition that causes sneezing, itching, and runny nose due to an allergic reaction. Fluticasone is not effective for a productive cough that produces mucus, and it may even worsen it by suppressing the immune system and increasing the risk of infection.

Choice C reason: Pseudoephedrine (Sudafed) is not the correct medication for a patient with a productive cough. Pseudoephedrine is a decongestant that works by constricting the blood vessels in the nasal passages and sinuses. Pseudoephedrine is used for nasal congestion, which is a condition that causes stuffy nose and difficulty breathing due to swelling of the mucous membranes. Pseudoephedrine is not effective for a productive cough that produces mucus, and it may even cause side effects such as increased blood pressure, insomnia, and anxiety.

Choice D reason: Guaifenesin (Mucinex) is the correct medication for a patient with a productive cough. Guaifenesin is an expectorant that works by thinning and loosening the mucus in the chest and throat. Guaifenesin is used for a productive cough that produces mucus, as it helps the cough to be more effective and clear the airways. Guaifenesin is generally safe and well tolerated, but it may cause some minor side effects such as nausea, vomiting, and headache.

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The nurse is preparing to administer Regular insulin to a client with a blood glucose of 265. What action should the nurse take to determine the correct dose?

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Naxlex Comprehensive Predictor Exams

A med-surg patient is scheduled to receive docusate (Colace) at 9am. The night nurse advises the patient had two loose stools during her shift. The nurse would anticipate:

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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