A nurse is caring for a client with diabetes mellitus who is prescribed regular insulin via a sliding scale. After administering the correct dose at 0715, the nurse should ensure the client receives breakfast at which of the following times?
0730
0745
0815
0720
The Correct Answer is A
Choice A reason:
0730: Regular insulin, also known as short-acting insulin, typically begins to work within 30 minutes after administration. Therefore, ensuring the client receives breakfast at 0730, which is 15 minutes after the insulin dose, aligns with the onset of insulin action. This timing helps to prevent hypoglycemia by ensuring that glucose from the meal is available when the insulin starts to lower blood sugar levels.
Choice B reason:
0745: Administering breakfast at 0745, which is 30 minutes after the insulin dose, might be slightly delayed. While it is still within the effective window, it is better to have the meal a bit earlier to ensure that glucose is available as soon as the insulin begins to act.
Choice C reason:
0815: Providing breakfast at 0815, which is an hour after the insulin dose, is too late. By this time, the insulin would have already started to lower blood glucose levels significantly, increasing the risk of hypoglycemia. It is crucial to match the timing of food intake with the insulin action to maintain stable blood sugar levels.
Choice D reason:
0720: Serving breakfast at 0720, which is only 5 minutes after the insulin dose, is too early. The insulin would not have started to act yet, and the blood glucose levels might rise too high before the insulin begins to lower them. It is important to wait at least 15-30 minutes after administering regular insulin before eating.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Saying “Maybe next time you can have a vaginal delivery” is not supportive and may minimize the client’s current feelings of disappointment. It is important to acknowledge and validate the client’s emotions rather than focusing on future possibilities.
Choice B reason:
This response, “It sounds like you are feeling sad that things didn’t go as planned,” is empathetic and validates the client’s feelings. It shows that the nurse is listening and understands the client’s disappointment, which is crucial for emotional support.
Choice C reason:
While it is true that having a healthy baby is important, saying “At least you know you have a healthy baby” can come across as dismissive of the client’s feelings. It is essential to address the client’s emotions directly rather than shifting the focus.
Choice D reason:
Telling the client “You can resume sensations sooner than if you had delivered vaginally” is not relevant to the client’s expressed feelings of disappointment about not having a natural childbirth. This response does not address the emotional aspect of the client’s experience.
Correct Answer is C
Explanation
Choice A reason:
Assist the client to sit upright in a chair for 4 hours at a time: While it is important to mobilize patients after surgery, sitting upright for 4 hours at a time is excessive and can cause discomfort and strain on the surgical site. Early postoperative care focuses on gradual mobilization and avoiding prolonged positions that could stress the spine.
Choice B reason:
Expect clear drainage on the spinal dressing: Clear drainage on the spinal dressing is not typical and could indicate a cerebrospinal fluid (CSF) leak, which is a serious complication. Any unexpected drainage should be reported to the healthcare provider immediately.
Choice C reason:
Log roll the client every 2 hours: Log rolling is a technique used to turn patients while keeping the spine in alignment. This method is crucial for patients who have undergone spinal surgery to prevent twisting or bending of the spine, which could disrupt the surgical site and impede healing. Regular repositioning also helps prevent pressure ulcers.
Choice D reason:
Perform neurological checks every 8 hours: Neurological checks are essential after spinal surgery to monitor for any changes in sensation, movement, or function. However, these checks are typically performed more frequently than every 8 hours, especially in the immediate postoperative period.
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