A client receives the morning dose of 10 units of insulin aspart at 0800. At what time would the nurse monitor for hypoglycemia?
1200
1000
0900
1100
The Correct Answer is C
Choice A Reason
Monitoring for hypoglycemia at 1200 is not optimal because it is well past the peak action time of insulin aspart, which occurs approximately 45–90 minutes after administration. By noon, the insulin's effects are waning, and the risk of hypoglycemia is lower compared to the peak action period.
Choice B Reason
Monitoring at 1000 might still catch the tail end of the peak action time, but it is not the most likely time for hypoglycemia to occur. The nurse could miss the initial signs of hypoglycemia if monitoring starts two hours after administration.
Choice C Reason
0900 is the most appropriate time for the nurse to monitor for hypoglycemia. Insulin aspart has a rapid onset of action, peaking in about 45–90 minutes, and the effects last for 3–5 hours. Monitoring one hour after administration aligns with the start of the peak action time, when hypoglycemia is most likely to occur.
Choice D Reason
Monitoring at 1100 is less ideal because it is nearing the end of the peak action period. While there is still a risk for hypoglycemia, the highest risk would have been earlier, closer to the peak action time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason
Intervening when a client attempts self-injury may be necessary to ensure the client's immediate safety. However, this action does not primarily implement the ethical principle of autonomy. Autonomy involves respecting the client's right to make their own decisions, including the right to refuse treatment. In cases of self-harm, the nurse must balance the ethical principles of autonomy and nonmaleficence (the duty to do no harm)
Choice B Reason
Suggesting restrictions for clients who were fighting might be a measure to maintain safety within the unit. However, this suggestion does not uphold the principle of autonomy, as it involves limiting the clients' freedom and choices. The ethical principle of autonomy emphasizes the clients' right to make independent choices and to control their own actions.
Choice C Reason
Staying with a client who is experiencing a high level of anxiety is a supportive action that can be therapeutic. While it demonstrates care and may provide comfort, it does not directly implement the principle of autonomy. Autonomy is about the capacity to make informed and voluntary decisions, and while support is important, it does not equate to enabling decision-making.
Choice D Reason
Exploring alternative solutions with a client and allowing them to choose an option embodies the ethical principle of autonomy. This approach respects the client's right to be involved in their own care and to make decisions based on their values and beliefs. It empowers the client to have control over their treatment and respects their capacity for self-determination.
In psychiatric nursing, respecting autonomy means acknowledging the client's right to make choices about their care and treatment. It involves providing all necessary information and supporting the client in making informed decisions. By exploring options and allowing the client to choose, the nurse facilitates autonomy and supports the client's right to direct their own care.
Correct Answer is A
Explanation
Choice a reason:
Bleeding at the arterial puncture site is a primary concern post-cardiac angiogram, as it can lead to significant blood loss and hematoma formation. The nurse must frequently monitor the site for any signs of bleeding or hematoma, apply pressure if necessary, and report any abnormalities to the physician immediately.
Choice b reason:
Cardiac dysrhythmias may occur due to irritation of the heart muscle by the catheter during insertion. Monitoring the client's heart rhythm is essential to detect any new onset of arrhythmias, which could indicate complications from the procedure.
Choice c reason:
Electrolyte imbalances can result from the contrast dye used during a cardiac angiogram. The dye can affect kidney function, leading to changes in electrolyte levels. Monitoring electrolyte levels is important to prevent complications such as arrhythmias or fluid imbalances.
Choice d reason:
While discomfort at the catheter insertion site is expected, it is typically mild. However, the nurse should assess for discomfort as it may indicate other issues such as infection, bleeding, or a reaction to the procedure.
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