Exhibits

It is 1800, and the client has a scheduled dose of insulin glargine due. The client has a regular diet tray ordered with 60 carbohydrates. The tray has not yet arrived in the room.

For each nursing action below, click to specify if the action is indicated, contraindicated or nonessential. Each row must have one option selected.

Give insulin lispro 4 units

Verify that the client can count carbohydrates

Mix the insulin lispro and insulin glargine in one syringe

Give insulin glargine 12 units

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"}}

Give insulin lispro 4 units: Contraindicated - Insulin lispro is a rapid-acting insulin that should be given in relation to meal intake. Since the client's meal tray has not arrived, administering insulin lispro could lead to hypoglycemia.
Verify that the client can count carbohydrates: Nonessential - While it’s useful to know if a client can count carbohydrates, it’s not critical for administering scheduled long-acting insulin like insulin glargine.
Mix the insulin lispro and insulin glargine in one syringe: Contraindicated - Insulin glargine is a long-acting insulin and should not be mixed with other insulins in the same syringe.
Give insulin glargine 12 units: Indicated - Insulin glargine is a long-acting insulin that is typically given at a set time each day and is not dependent on immediate food intake, so it is appropriate to administer the scheduled dose.

Nursing Test Bank

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Correct Answer is B

Explanation

A. A metal hip prosthesis does not generally interfere with CT scans or contrast use.
B. Metformin use requires follow-up because contrast agents can affect renal function, potentially increasing the risk of lactic acidosis in clients taking metformin.
C. Sobriety is not directly relevant to the CT scan or contrast administration.
D. The timing of a previous CT scan is not a concern unless it affects contrast use or renal function, which is not indicated here.

A. Monitor vital signs continuously B. Echocardiogram C. Assess rash D. Administer antihistamine E. Assess lung sounds F. Provide calm environment G. Provide warmth H. Defibrillator at bedside I. Administer steroid J. IV fluids K. Pain medication L. Chest x-ray

Correct Answer is ["A","B","C","D","E","F"]

Explanation

Monitor vital signs continuously: This is crucial to detect any further changes in heart rate or blood pressure, especially given the client’s history of symptomatic bradycardia and recent hypotensive episode following vancomycin administration.

Echocardiogram: This is appropriate post-pacemaker insertion to assess cardiac function and ensure the pacemaker is functioning properly.

Immunological:

Administer antihistamine: Given the client’s adverse reaction to vancomycin, which included hives, flushing, and itching, administering an antihistamine like diphenhydramine is appropriate.

Assess rash: Monitoring the progression or improvement of the rash will help evaluate the effectiveness of the interventions and the resolution of the allergic reaction.

Respiratory:

Assess lung sounds: It's important to evaluate the client’s respiratory status, especially given the shortness of breath reported post-operatively, which could indicate a reaction to the medication or a complication from the procedure.

Provide calm environment: This intervention helps in reducing anxiety and stress, which can exacerbate symptoms and impact cardiovascular and respiratory status.

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Body system	Potential nursing intervention
Cardiovascular	Monitor vital signs continuously Provide warmth Echocardiogram Defibrillator at bedside
Immunological	Administer steroid Assess rash IV fluids Administer antihistamine
Respiratory	Assess lung sounds Pain medication Provide calm environment Chest x-ray

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is scheduled for a spiral computed tomography (CT) scan with contrast to evaluate for pulmonary embolism. Which information in the client's history requires follow-up by the nurse?

Correct Answer is B

Explanation

Correct Answer is ["A","B","C","D","E","F"]

Explanation

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