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Patient Data

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 site for the insulin administration

The insulin vial for color and clarity

The dose of insulin drawn up in the syringe

The insulin concentration

The expiration date on the insulin vial

The sliding scale insulin lispro prescription

The history and physical with the diabetes diagnosis listed

The type of insulin to be administered

Answer and Explanation

Correct Answer : C,D,F,H

A. The site for the insulin administration: While site selection is important for absorption consistency, double-checking the injection site with another nurse is not required under insulin safety protocols. It is an individual nursing responsibility.

B. The insulin vial for color and clarity: Although inspecting insulin for proper color and clarity is critical, it does not formally require double-checking with another nurse. It is part of standard administration checks performed by the individual nurse.

C. The dose of insulin drawn up in the syringe: Double-checking the correct dose with another nurse is essential to prevent dosing errors. Insulin is considered a high-alert medication, and the dose must be verified to ensure client safety.

D. The insulin concentration: Insulin comes in different concentrations (e.g., U-100, U-500). Verifying the concentration with a second nurse is vital to avoid giving the wrong dose based on an incorrect strength.

E. The expiration date on the insulin vial: Checking the expiration date is necessary, but it does not formally require a second nurse verification. It is part of safe medication administration practices.

F. The sliding scale insulin lispro prescription: Ensuring the sliding scale prescription is accurately followed is crucial. Double-checking that the blood glucose reading matches the correct insulin dose according to the sliding scale prevents errors.

G. The history and physical with the diabetes diagnosis listed: Confirming a diagnosis is useful background information but is not necessary to double-check before insulin administration. The medication order itself already assumes the clinical need.

H. The type of insulin to be administered: Verifying that the correct type of insulin (e.g., insulin lispro for rapid-acting) is being used is mandatory. A second nurse must confirm that the right insulin type matches the order to avoid administration mistakes.

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Correct Answer is B

Explanation

A. Administer an oral analgesic and evaluate its effectiveness before applying the new patch: There is no need to switch to oral analgesics if the client is already well-managed on a fentanyl patch. The focus should be on properly managing the patch schedule rather than changing the route of administration.

B. Apply the new patch in a different location after removing the original patch: Proper protocol for transdermal patches includes removing the old patch before applying a new one to prevent overdose. The new patch should be placed on a different skin site to avoid skin irritation and ensure even drug absorption.

C. Place the patch on the client's shoulder and leave both patches in place for 12 hours: Leaving both patches in place can lead to dangerously high serum fentanyl levels and significant respiratory depression. Only one patch should be used at a time unless otherwise specifically prescribed.

D. Remove the patch and consult with the healthcare provider (HCP) about the client's pain resolution: It is unnecessary to contact the HCP immediately if the client is pain-free and the scheduled time for patch replacement has arrived. Standard procedure should be followed by simply removing the old patch and applying the new one.

A. Compress the client's nares. B. Observe for facial flushing. C. Advise the client to rest. D. Elevate the client's feet.

Correct Answer is C

Explanation

A. Compress the client's nares: Compressing the nares is a technique used for nasal medication administration or controlling nosebleeds, not for sublingual or oral spray forms of nitroglycerin. This action is unrelated to nitroglycerin use for angina.

B. Observe for facial flushing: Facial flushing is a common side effect of nitroglycerin due to vasodilation. While it should be noted during monitoring, it is not the immediate next action after administration when addressing angina symptoms.

C. Advise the client to rest: Resting after nitroglycerin administration reduces myocardial oxygen demand, helping to relieve anginal pain more effectively. It also helps prevent hypotension and dizziness, which are common side effects of the medication.

D. Elevate the client's feet: Elevating the feet is typically done if hypotension occurs. It is not a standard next step immediately after giving nitroglycerin unless the client shows symptoms like syncope or significant blood pressure drops.

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Patient Data 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

After administering nitroglycerin spray to a client experiencing angina, which action should the nurse implement next?

Correct Answer is C

Explanation

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The mother of an adolescent male tells the clinic nurse that she found anabolic steroids in her son's room. How should the nurse respond? Select all that apply.

Patient Data

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.