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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: Gum appearance is unrelated to carbamazepine’s side effects or sore throat. While some antiseizure drugs cause gingival hyperplasia, carbamazepine does not, and gum assessment does not clarify the sore throat’s cause, which may indicate infection or agranulocytosis, making this choice irrelevant.

Choice B reason: Bowel sounds assess gastrointestinal function, not relevant to a sore throat or carbamazepine’s effects. Sore throat may signal agranulocytosis, a rare side effect, but bowel sounds do not provide data on infection or hematologic issues, making this choice inappropriate.

Choice C reason: Carotid pulse volume evaluates cardiovascular status but is unrelated to sore throat or carbamazepine’s side effects. Sore throat may indicate infection or agranulocytosis, requiring systemic assessment like temperature, not vascular checks, making this choice irrelevant for the reported symptom.

Choice D reason: Temperature is critical, as sore throat may indicate infection or agranulocytosis, a rare but serious carbamazepine side effect causing low white blood cells. Fever suggests infection, necessitating urgent reporting. This assessment provides key data to differentiate causes, guiding timely intervention.

A. Enjoys eating aged cheeses B. Soaks in a warm bath at night C. Reports frequent dryness in mouth D. Takes medication upon rising

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.

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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?

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Naxlex Comprehensive Predictor Exams

The practical nurse assesses a client who is receiving carbamazepine for a seizure disorder. The client reports the onset of a sore throat. Which additional assessment data should the PN obtain before reporting to the charge nurse?

Correct Answer is D

Explanation

A client with depression who is taking a tricyclic antidepressant (TCA) reports frequent early morning awakening and difficulty going back to sleep. Which information from the client is important for the practical nurse (PN) to obtain to improve the client’s sleep pattern?

Correct Answer is D

Explanation

A client receives a prescription for intravenous (IV) famotidine. Which finding indicates to the practical nurse (PN) the medication is effective?

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