A nurse is calculating the intake of a client during the past 9 hr. The client's intake includes lactated Ringer's IV at 150 mL/hr, cefazolin 2 g IV intermittent bolus in 100 mL of 0.9% sodium chloride, two units of packed RBCs of 275 mL and 250 mL; two IV bolus infusions of 250 mL of 6.0% sodium chloride, famotidine 20 mg IV intermittent bolus in 50 mL of 0.9% sodium chloride. How many mL of intake should the nurse record?

 

 

Choice A reason: Rotating the injection sites within the same location for a week is not correct. The client should rotate the injection sites within the same location each day to prevent lipodystrophy and ensure consistent absorption.

Choice B reason: Storing the unopened vials of insulin in the freezer is not correct. The client should store the unopened vials of insulin in the refrigerator, not the freezer, to prevent damage to the insulin.

Choice C reason: Drawing up the regular insulin before the NPH insulin is correct. The client should draw up the clear (regular) insulin before the cloudy (NPH) insulin to prevent contamination of the regular insulin with the NPH insulin.

Choice D reason: Injecting the insulin into the muscle for faster absorption is not correct. The client should inject the insulin into the subcutaneous tissue, not the muscle, to ensure appropriate absorption and prevent hypoglycemia.

Choice A reason: This is incorrect because withholding all medications may cause hyperglycemia or ketoacidosis in the patient, especially if they are taking insulin or sulfonylureas. The nurse should consult with the prescriber to adjust the dose or timing of the medications according to the patient's blood glucose level and the duration of the procedure.

Choice B reason: This is correct because contacting the prescriber to clarify orders is the best action by the nurse, as the prescriber can provide specific instructions on how to manage the patient's oral antidiabetic drugs before and after the oral endoscopy. The nurse should also monitor the patient's blood glucose level closely and report any abnormal findings to the prescriber.

Choice C reason: This is incorrect because administering half the original dose may not be appropriate for the patient, as it may cause hypoglycemia or hyperglycemia depending on the type and dose of the medication and the patient's blood glucose level. The nurse should not make any changes to the medication regimen without the prescriber's approval.

Choice D reason: This is incorrect because giving the medication with a sip of water may violate the NPO status of the patient, which is necessary to prevent aspiration or interference with the oral endoscopy. The nurse should not administer any oral medications or fluids to the patient unless the prescriber allows it.