A newly diagnosed diabetic client is 24 hours post-op following abdominal surgery.
The 0700 blood glucose level is 200 mg/dl and the nurse administers 4 units of insulin aspart subcutaneously per the prescribed sliding scale.
When should the nurse first assess the client for signs and symptoms of hypoglycemia?
0800
0730
1130
1000
The Correct Answer is B
Choice A rationale
Hypoglycemia, or low blood sugar, can occur after insulin administration. However, the onset of hypoglycemia is not immediate. Insulin aspart, a rapid-acting insulin, has a peak action time of approximately 1-3 hours after administration. Therefore, assessing the patient for signs and symptoms of hypoglycemia at 0800, one hour after administration, may be too early.
Choice B rationale
Assessing the patient for signs and symptoms of hypoglycemia at 0730, 30 minutes after insulin administration, is too early. The peak action time of insulin aspart is approximately 1-3 hours after administration. Therefore, the nurse should start assessing the patient for signs and symptoms of hypoglycemia closer to the time of peak action.
Choice C rationale
Assessing the patient for signs and symptoms of hypoglycemia at 1130, four and a half hours after insulin administration, may be too late. The peak action time of insulin aspart is approximately 1-3 hours after administration. Therefore, the nurse should start assessing the patient for signs and symptoms of hypoglycemia closer to the time of peak action.
Choice D rationale
Assessing the patient for signs and symptoms of hypoglycemia at 1000, three hours after insulin administration, is within the peak action time of insulin aspart. Therefore, this is the most appropriate time to start assessing the patient for signs and symptoms of hypoglycemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Placing the patient back on the heparin infusion and redrawing laboratory values would not be the appropriate next step. The INR of 1.9 is below the therapeutic range of 2.0 - 3.0 for most patients on warfarin. Therefore, the warfarin therapy is not yet fully effective, and there is no need to revert to heparin.
Choice B rationale
Asking the healthcare provider if the patient’s medication can be changed to rivaroxaban would not be the appropriate next step. Rivaroxaban is a different type of anticoagulant and would not necessarily be more effective in this situation.
Choice C rationale
Notifying the healthcare provider and asking if the dose of warfarin can be increased would be the appropriate next step. The INR of 1.9 is below the therapeutic range of 2.0 - 3.0 for most patients on warfarin. Therefore, an increase in the warfarin dose may be necessary to achieve therapeutic anticoagulation.
Choice D rationale
Preparing to administer a dose of Vitamin K subcutaneously would not be the appropriate next step. Vitamin K is used to reverse the effects of warfarin and would be counterproductive in this situation.
Correct Answer is D
Explanation
Choice A rationale
The Trendelenburg position, with the stump supported on three pillows, is not typically recommended following a below-the-knee amputation. This position could increase the risk of contractures.
Choice B rationale
Side lying with the amputated leg flexed is not typically recommended following a below-the- knee amputation. This position could increase the risk of contractures.
Choice C rationale
Lying prone for 24 hours is not typically recommended following a below-the-knee amputation. While some prone positioning may be beneficial to prevent hip flexion contractures, it should not be the only position used.
Choice D rationale
The supine position, with the stump flat on the bed, is often recommended following a below- the-knee amputation. This position helps to prevent contractures and promotes healing.
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