A nurse administered insulin lispro via subcutaneous injection. What action should the nurse perform next?
Identify the client using two identifiers.
Verify the insulin dose with another nurse.
Gently roll the vial between hands to mix.
Continue to monitor the client for hypoglycemia.
The Correct Answer is D
A. Identify the client using two identifiers: Client identification is a critical safety step prior to medication administration, not after the insulin has already been given. Performing this step post-administration does not enhance immediate safety or therapeutic monitoring.
B. Verify the insulin dose with another nurse: Dose verification is an essential safety measure before administration, especially with high-alert medications like insulin. After administration, verifying the dose again does not prevent adverse events that could occur from an incorrect dose already given.
C. Gently roll the vial between hands to mix: Mixing the insulin by rolling the vial is performed prior to drawing up the medication to ensure uniform concentration, not after injection. Post-administration rolling has no clinical benefit.
D. Continue to monitor the client for hypoglycemia: Monitoring for hypoglycemia is critical after administering rapid-acting insulin like lispro. Insulin lowers blood glucose quickly, and clients are at risk for symptoms such as sweating, shakiness, confusion, or seizures, making vigilant post-administration observation essential.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E"]
Explanation
A. Antacid: Acetaminophen does not neutralize stomach acid or alter gastric pH. Antacid properties are unrelated to its mechanism of action, which is focused on central inhibition of prostaglandin synthesis rather than gastrointestinal acid modulation.
B. Anti-inflammatory: Unlike NSAIDs, acetaminophen has minimal to no peripheral anti-inflammatory effect. It primarily acts centrally in the CNS, reducing pain perception and fever without significant impact on inflammatory processes.
C. Analgesic: Acetaminophen provides pain relief by inhibiting central prostaglandin synthesis, which decreases the perception of pain. It is effective for mild to moderate pain, such as headaches, musculoskeletal pain, and postoperative discomfort.
D. Antidiarrheal: Acetaminophen does not affect gastrointestinal motility or secretions and therefore has no role in treating diarrhea. Its pharmacologic effects are limited to analgesia and fever reduction.
E. Antipyretic: Acetaminophen reduces fever by acting on the hypothalamic heat-regulating center, promoting vasodilation and sweating. This thermoregulatory effect helps lower elevated body temperature in febrile conditions.
Correct Answer is C
Explanation
A. "I can stop monitoring my blood glucose levels.": Sitagliptin helps lower blood glucose but does not replace the need for regular monitoring. Clients must continue self-monitoring to ensure safe and effective glycemic control and detect hyperglycemia or hypoglycemia.
B. "I should avoid carbohydrates while taking sitagliptin.": While a balanced diet is important, clients do not need to completely avoid carbohydrates. Sitagliptin enhances incretin effects to regulate insulin and glucagon but does not eliminate the need for dietary carbohydrates or proper nutrition.
C. "I know headaches are a common side effect.": Headache is a documented and relatively common adverse effect of sitagliptin. This statement reflects an understanding of the medication’s potential side effects, allowing the client to anticipate and manage minor discomfort appropriately.
D. "I will inject this medication daily at the same time.": Sitagliptin is an oral dipeptidyl peptidase-4 (DPP-4) inhibitor, not an injectable medication. Planning to inject it reflects a misunderstanding of its route of administration and pharmacologic form.
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