For each nursing action listed, click to specify whether the action should be completed before administration or after administration of insulin.
Check client's blood glucose level
Assess client at the time of peak effect
Identify client using 2 identifiers
Document time and injection site
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"}}
• Check client's blood glucose level: Assessing blood glucose prior to insulin administration ensures the correct dose is given and prevents hypoglycemia. Pre-administration checks allow safe and individualized dosing based on current glucose levels.
• Identify client using 2 identifiers: Verifying the client’s identity with two identifiers (e.g., name and date of birth) is essential before giving insulin to prevent medication errors and ensure patient safety.
• Assess client at the time of peak effect: Monitoring the client during the insulin’s peak effect helps detect hypoglycemia, the time when the drug’s action is strongest. Post-administration assessment ensures prompt intervention if adverse effects occur.
• Document time and injection site: Recording the time and site of insulin injection after administration provides a reference for subsequent doses and site rotation. Accurate documentation helps prevent complications such as lipodystrophy and ensures continuity of care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Recognize cues: This step involves identifying and interpreting relevant clinical data, such as signs of hypoglycemia (e.g., sweating, shakiness, pallor). While necessary for decision-making, recognizing cues alone does not include the actual intervention.
B. Generate solutions: In this step, the nurse considers possible interventions or strategies to address the identified problem. It is a planning phase and does not involve carrying out the intervention yet.
C. Take action: Administering oral glucose is the execution of the planned intervention to treat hypoglycemia. This step reflects implementing the clinical decision based on the identified cues and chosen solution, directly affecting the client’s immediate status.
D. Evaluate outcomes: This step occurs after the intervention, when the nurse assesses the effectiveness of the action, such as improved blood glucose levels and resolution of hypoglycemic symptoms. It does not include the initial administration of treatment.
Correct Answer is D
Explanation
A. A client with a low serum albumin: Low albumin levels affect protein binding of highly protein-bound drugs, increasing the free drug concentration and potential toxicity. While this influences drug distribution and effects, it does not directly impair hepatic metabolism.
B. A client diagnosed with renal failure: Renal failure primarily affects drug excretion rather than metabolism. Drugs cleared by the kidneys may accumulate, but hepatic metabolism may remain largely intact unless concomitant liver disease is present.
C. A client with slowed gastric emptying: Slowed gastric emptying affects the rate and sometimes the extent of drug absorption. While this can delay onset of action, it does not significantly alter hepatic metabolism of the medication.
D. A client with cirrhosis of the liver: Cirrhosis significantly impairs hepatic function, reducing the liver’s ability to metabolize drugs through phase I and phase II reactions. This increases drug half-life, risk of accumulation, and potential toxicity, making these clients the highest risk for decreased drug metabolism.
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