A nurse is reinforcing teaching with a client who has diabetes mellitus and is taking insulin lispro and insulin glargine. Which of the following instructions should the nurse include in the teaching?

"Draw up the insulin lispro and insulin glargine in separate syringes."

"Expect insulin glargine to be cloudy."

“Take an extra dose of insulin lispro prior to aerobic exercise."

"Anticipate that the insulin glargine will peak in 3 hours."

Answer and Explanation

The Correct Answer is A

Insulin lispro is a rapid-acting insulin, while insulin glargine is a long-acting insulin. It is important to keep them separate to maintain their individual properties and avoid any potential interactions or changes in their effectiveness.

Insulin glargine is a clear solution and should not appear cloudy. Cloudiness in insulin can indicate contamination or improper storage.

The instruction to "take an extra dose of insulin lispro prior to aerobic exercise" is not recommended. The client should consult with their healthcare provider to determine if any adjustments to their insulin regimen are necessary for exercise. Typically, adjustments are made based on the individual's blood glucose levels and anticipated intensity and duration of exercise. Insulin glargine is a long-acting insulin that provides a steady release of insulin over a prolonged period, without distinct peaks or valleys in its action. Its onset of action is gradual and its effect lasts for approximately 24 hours.

It is important for the client to receive accurate and appropriate instructions regarding their insulin regimen. The nurse should clarify any misunderstandings and provide accurate information to promote safe and effective diabetes management.

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Correct Answer is B

Explanation

Hypertensive crisis is a severe increase in blood pressure that can lead to organ damage or other complications. Prompt assessment and intervention are necessary to prevent further escalation of blood pressure and potential complications.

While all the clients mentioned require attention, the client with elevated blood pressure and a headache poses a higher immediate risk. The nurse should assess the client's blood pressure, evaluate for signs of target organ damage, and initiate appropriate interventions, which may include administering antihypertensive medications as prescribed and monitoring closely for any changes in the client's condition.

The client who is postoperative and reports intermittent nausea can be assessed and managed after addressing the client with the elevated blood pressure and headache.

The client scheduled for surgery in 2 hours can be addressed according to the scheduled timeline.

A. Locks the wheels on the client's bed B. Clears furniture from the path leading to the bathroom C. Assists the client to the bathroom every 2 hr D. Raises all four side-rails on the client's bed

Correct Answer is D

Explanation

The nurse should intervene when the AP raises all four side-rails on the client's bed. While it is important to ensure the client's safety and minimize the risk of falls, raising all four side-rails can be considered a restraint and may not be the best practice for fall prevention. The use of physical restraints, including all four side-rails, can lead to adverse outcomes such as entrapment, increased agitation, and decreased mobility.

Locking the wheels on the client's bed: This is an appropriate action to prevent the bed from rolling and ensures stability.

Clearing furniture from the path leading to the bathroom: This is a good practice as it creates a clear and safe path for the client to walk without obstacles.

Assisting the client to the bathroom every 2 hours: This is a proactive measure to prevent falls by ensuring regular toileting and minimizing the need for the client to get up and move independently.

It's important to promote mobility and independence for the client while ensuring their safety.

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A nurse is reinforcing teaching with a client who has diabetes mellitus and is taking insulin lispro and insulin glargine. Which of the following instructions should the nurse include in the teaching?

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Correct Answer is D

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