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Exhibits

The nurse prepares to give 2 units of insulin lispro.

Which should the nurse double check with a second nurse? Select all that apply.

The dose of insulin drawn up in the syringe

The site for the insulin administration

The type of insulin to be administered

The sliding scale insulin lispro prescription

The insulin concentration

The insulin vial for color and clarity

The history and physical with the diabetes diagnosis listed

The expiration date on the insulin vial

Answer and Explanation

Correct Answer : A,C,D,E,F,H

A. (The dose of insulin drawn up in the syringe): Ensures the correct dosage is being administered, which is critical to avoid under- or overdosing.
B. The site for the insulin administration is not typically double-checked with another nurse, as they are part of the nurse's standard assessment and practice.
C. (The type of insulin to be administered): Confirms that the correct insulin type (e.g., insulin lispro) is being given, as administering the wrong type could lead to improper glucose control.
D. (The sliding scale insulin lispro prescription): Verifies the correct sliding scale dosing, ensuring it matches the client's current blood glucose level.
E. (The insulin concentration): Ensures the insulin concentration is appropriate and aligns with the prescribed dose.
F. (The insulin vial for color and clarity): Confirms that the insulin is not compromised; any discoloration or cloudiness could indicate that the insulin is not safe to use.
H. (The expiration date on the insulin vial): Ensures the insulin is within its expiration date and effective.
G. The history and physical with the diabetes diagnosis listed are not typically double-checked with another nurse, as they are part of the nurse's standard assessment and practice.

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Correct Answer is B

Explanation

A. Administering an oral analgesic is not necessary if the client is not currently experiencing pain and it does not address the need to replace the transdermal patch as scheduled.
B. Fentanyl transdermal patches should be applied to a different location after the original patch is removed. This ensures consistent pain management while preventing skin irritation or overdose.
C. Leaving both patches in place can lead to overdose due to excessive fentanyl absorption. D. While consulting the healthcare provider may be warranted if the client no longer needs opioid analgesia, it is not the immediate action in this scenario.

A. Advise the caregiver that the purpose of the medication is to promote sleep, so a change in medication may be needed. B. Explain to the caregiver that insomnia is a common and temporary side effect when the medication is first started. C. Instruct the caregiver to withhold the medication until the dosage can be decreased to ensure the client's safety. D. Notify the healthcare provider that the dosage of the medication may need to be increased to manage the client's insomnia.

Correct Answer is B

Explanation

A. Rivastigmine is used to improve cognitive function in Alzheimer's disease and not specifically to promote sleep, so suggesting a medication change is not appropriate without further assessment.
B. Insomnia can be a side effect of rivastigmine, especially when starting the medication. It is often temporary and should improve as the body adjusts.
C. Withholding the medication or changing the dosage without guidance from the healthcare provider could impact the client's cognitive function and should not be done based on a single side effect.
D. Increasing the dosage of rivastigmine is not a solution for insomnia and could potentially exacerbate other side effects.

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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

Exhibits The nurse prepares to give 2 units of insulin lispro. Which should the nurse double check with a second nurse? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When preparing to apply a scheduled fentanyl transdermal patch, the nurse notes that the previously applied patch is intact on the client's upper back and the client denies pain. Which action should the nurse take?

Correct Answer is B

Explanation

During a home visit, the nurse assesses a client with Alzheimer's disease who recently started a new prescription for rivastigmine. The caregiver reports that the client seems to be thinking more clearly but is not sleeping well at night. Which action should the nurse take?

Correct Answer is B

Explanation

A client with a history of chronic obstructive pulmonary disease (COPD) receives a new prescription for an ipratropium inhaler. Which action indicates to the nurse that additional teaching is needed?

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Based on a client's serum digoxin level, the client is diagnosed with digoxin toxicity. Which action should the nurse expect to implement?

A client with a cold is taking the antitussive medication benzonatate. Which assessment information indicates to the nurse that the medication is effective?

Before administering a laxative to a bedfast client, it is most important for the nurse to perform which assessment?

Exhibits

The nurse prepares to give 2 units of insulin lispro.

Which should the nurse double check with a second nurse? Select all that apply.