After administering the client’s 0730 prescribed dose of regular insulin per a sliding scale, which action by the practical nurse (PN) has the highest priority?
Instruct the unlicensed assistive personnel (UAP) to take the client a breakfast tray
Observe the client for pallor, diaphoresis, or fatigue
Measure the client’s vital signs and oxygen saturation
Notify the charge nurse of the dose of insulin administered
The Correct Answer is B
Choice A reason: Instructing the UAP to bring a breakfast tray ensures nutritional support but is not the highest priority. Regular insulin peaks within 2–4 hours, risking hypoglycemia if not monitored. Observing for hypoglycemic symptoms takes precedence to ensure immediate safety post-administration.
Choice B reason: Observing for pallor, diaphoresis, or fatigue is critical, as these indicate hypoglycemia, a serious risk after regular insulin administration. Insulin lowers blood glucose, and rapid drops can impair brain function or cause seizures. Monitoring for these signs ensures timely intervention, prioritizing client safety.
Choice C reason: Measuring vital signs and oxygen saturation provides general data but is less specific than monitoring for hypoglycemia symptoms. Regular insulin’s rapid action increases hypoglycemic risk, and symptoms like diaphoresis are more direct indicators, making this choice secondary to targeted observation.
Choice D reason: Notifying the charge nurse of the insulin dose is routine but not urgent. The priority is monitoring for hypoglycemia, as regular insulin can cause rapid glucose drops, leading to serious complications. Immediate client observation outweighs administrative tasks in ensuring safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Eating aged cheeses, high in tyramine, is relevant for monoamine oxidase inhibitors, not TCAs, which do not interact with tyramine. This dietary habit does not affect TCA-related sleep disturbances, making it irrelevant for addressing the client’s early morning awakening.
Choice B reason: Taking a warm bath at night may promote relaxation but does not directly address TCA-related sleep issues. While helpful for general sleep hygiene, it is less critical than medication timing, which directly influences TCA’s stimulatory effects on sleep patterns.
Choice C reason: Dry mouth is a common TCA side effect due to anticholinergic properties but is not directly linked to sleep disturbances. It may cause discomfort but does not explain or address early morning awakening, making this information less relevant for sleep improvement.
Choice D reason: Taking TCAs upon rising can cause insomnia, as their stimulatory effects peak during sleep hours. TCAs increase norepinephrine, disrupting sleep architecture. Adjusting to bedtime dosing may reduce early morning awakening, making this information critical for optimizing sleep and therapeutic outcomes.
Correct Answer is D
Explanation
Choice A reason: Using an Amsler grid monitors macular degeneration, not sildenafil-related visual changes, which include color tinting or blurred vision due to PDE5 inhibition affecting retinal blood flow. This is not a standard monitoring tool for sildenafil side effects, making it inappropriate for this context.
Choice B reason: Instilling eye drops is irrelevant, as sildenafil’s visual changes are systemic, caused by its effect on retinal phosphodiesterase, not a local eye condition treatable with drops. No evidence supports eye drops for this side effect, making this choice incorrect and ineffective.
Choice C reason: Wearing dark glasses may reduce light sensitivity but does not address sildenafil’s visual side effects, like blue-green color distortion, caused by altered retinal signaling. This is a temporary, drug-induced effect, and glasses do not mitigate the underlying issue, making this choice inadequate.
Choice D reason: Reporting visual changes immediately is critical, as sildenafil can cause rare but serious effects like non-arteritic anterior ischemic optic neuropathy, impairing retinal blood flow. Prompt reporting allows the provider to assess severity, adjust dosing, or discontinue the drug to prevent permanent vision loss.
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