A nurse is preparing to administer 5 units of regular insulin and 20 units of NPH insulin to a client who has type 1 diabetes mellitus. Which of the following actions should the nurse take first?
Inject 20 units of air into the vial of NPH insulin.
Inject 5 units of air into the vial of regular insulin.
Withdraw 20 units of NPH insulin from the vial.
Withdraw 5 units of regular insulin from the vial.
The Correct Answer is A
Answer: (A) Inject 20 units of air into the vial of NPH insulin.
Rationale:
A) Inject 20 units of air into the vial of NPH insulin:
Injecting air into the vial of NPH insulin is the first step to prevent creating a vacuum, which could make it difficult to withdraw the insulin later. The nurse must inject the corresponding amount of air for the dose needed, ensuring that the insulin can be withdrawn smoothly and accurately without bubbles, which could affect the dose.
B) Inject 5 units of air into the vial of regular insulin:
Injecting air into the regular insulin vial is also necessary before withdrawing the insulin, but it should be done after injecting air into the NPH vial. This sequence ensures that no NPH insulin contaminates the regular insulin vial when the nurse withdraws the doses later.
C) Withdraw 20 units of NPH insulin from the vial:
Withdrawing NPH insulin should be done after air is injected into both vials and after the regular insulin has been drawn up. This sequence prevents the mixing of the two types of insulin and ensures accurate dosing, which is crucial for maintaining the correct blood glucose levels.
D) Withdraw 5 units of regular insulin from the vial:
Withdrawing regular insulin is critical to do before the NPH insulin to prevent contamination of the regular insulin with NPH, which could alter the onset and peak times of the regular insulin. However, it should follow the steps of injecting air into both vials, starting with the NPH vial.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
d. Apply the dressing loosely over the incision.
Explanation:
The correct answer is d. Apply the dressing loosely over the incision.
When caring for an older adult client, it is important for the nurse to be sensitive to age-related changes and promote their comfort and well-being. Applying the dressing loosely over the incision allows for beter circulation and ventilation, which can help prevent complications such as skin breakdown and infection.
Option a is not the correct answer. Asking the client to help with the dressing change may not be appropriate, as postoperative clients, especially older adults, may have limited mobility or dexterity. It is the nurse's responsibility to provide the necessary care and support during the dressing change.
Option b is not the correct answer. Waiting for the client to approach the nurse for assistance may lead to delays in care and could potentially compromise the client's healing process. The nurse should proactively assess the client's needs and provide appropriate care.
Option c is not the correct answer. Using paper tape for securing the new dressing does not specifically address sensitivity to age-related changes. While paper tape may be gentle on the skin, it is not the primary consideration in this situation.
By applying the dressing loosely over the incision, the nurse demonstrates sensitivity to age-related changes and promotes the client's comfort and optimal healing. This approach takes into account the potential for decreased skin elasticity and fragility in older adults, allowing for proper circulation and reducing the risk of complications.
Correct Answer is B
Explanation
The client has state-sponsored health insurance: While information about the client's health insurance coverage is important for billing and financial purposes, it may not be directly relevant to the discussion in an interprofessional team meeting unless it specifically impacts the client's access to healthcare resources or affects decision-making regarding their care plan.
The reason for including this information is that difficulty ambulating can impact the client's overall mobility and functional status. It can have implications for their ability to perform activities of daily living, increase the risk of falls, and require additional interventions or resources. By sharing this information with the interprofessional team, appropriate strategies and interventions can be discussed and implemented to address the client's mobility issues.
The client's next dressing change is scheduled in 4 hours: The timing of the client's dressing change may be important for nursing documentation and scheduling purposes. However, it may not be a significant focus of discussion in an interprofessional team meeting unless there are specific concerns or issues related to the dressing change that require collaboration and coordination among the healthcare team.
The client's vital signs are checked every 8 hours: The frequency of vital sign checks is an important aspect of nursing care and monitoring. However, unless there are specific concerns or deviations from normal vital signs that need to be discussed, it may not be the primary information to include in an interprofessional team meeting. The focus of the meeting is typically on broader aspects of the client's condition, care plan, and multidisciplinary interventions.
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