Patient Data

Exhibits

The nurse should base insulin lispro administration on the client's anticipated intake of carbohydrates. The tray has not yet arrived in the room.

For each nursing action below, click to specify if the action is indicated, contraindicated or nonessential. Each row must have one option selected.

Give insulin lispro 4 units

Restart the IV fluids until the tray arrives

Give insulin glargine 12 units

Mix the insulin lispro and insulin glargine in one syringe

Verify that the client intake matches the carbohydrate count

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Give insulin lispro 4 units: Administering insulin lispro before the meal tray arrives is contraindicated because it can cause hypoglycemia if the client does not eat immediately. Insulin lispro should be given based on the exact carbohydrate intake, which cannot be determined until food is present.

Restart the IV fluids until the tray arrives: Restarting the IV fluids is indicated because it helps maintain hydration, especially important for a client with hyperglycemia and recent surgery. Fluids support perfusion and protect against dehydration while waiting for the client's nutritional intake to resume.

Give insulin glargine 12 units: Giving insulin glargine now is contraindicated because the client already received her scheduled dose earlier in the morning before surgery. Re-administering it could cause insulin stacking and dangerously low blood sugar later.

Mix the insulin lispro and insulin glargine in one syringe: Mixing insulin lispro and insulin glargine together is contraindicated because glargine is designed to maintain a stable, long-acting release. Mixing it can alter its absorption profile, making it unsafe to combine in the same syringe.

Verify that the client intake matches the carbohydrate count: This action is indicated because insulin lispro is prescribed to match the carbohydrate content of meals. Verifying the number of carbohydrates ensures the correct lispro dose is administered and helps prevent dosing errors and hypoglycemia.

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Free Nursing Study Resources

Correct Answer is ["B","C","D"]

Explanation

A. May stop taking medication if no symptoms of GI discomfort: Pantoprazole is prescribed prophylactically in burn clients to prevent stress ulcers, not just to treat existing symptoms. Stopping it without medical advice could increase the risk of serious complications like gastric bleeding.

B. Explain that pantoprazole may be taken with or without food: Pantoprazole, a proton pump inhibitor (PPI), can be taken without regard to meals. Educating the client on flexible timing improves adherence and reduces confusion about the medication regimen.

C. Teach the client about risk of developing a Curling's ulcer: Severe burns increase the risk of Curling’s ulcer, a stress-related gastric ulcer. Explaining this risk helps the client understand the preventative role of pantoprazole in their overall care plan.

D. Discuss the risk of gastric bleeding related to severe burns: Gastric bleeding is a serious, potentially life-threatening complication associated with stress ulcers in burn patients. Teaching the client about this risk provides a clear rationale for continuing pantoprazole therapy.

E. Tell how pantoprazole effectively heals ulcers: While pantoprazole can treat ulcers, in this case it is prescribed to prevent ulcer formation rather than to heal an existing ulcer. The teaching should focus on prevention, not healing.

A. Evaluate muscle strength every 4 hours. B. Advise the client to move slowly and cautiously when rising and walking. C. Ensure the client knows to stop baclofen before using other antispasmodics. D. Monitor intake and output every 8 hours.

Correct Answer is B

Explanation

A. Evaluate muscle strength every 4 hours: While assessing muscle strength is important in clients with multiple sclerosis, it does not need to be done this frequently unless the client is unstable. Baclofen may cause weakness, but routine assessments every 4 hours are excessive for stable patients.

B. Advise the client to move slowly and cautiously when rising and walking: Baclofen can cause dizziness, sedation, decreased muscle tone and orthostatic hypotension, particularly in the early stages of treatment. Educating the client to change positions carefully helps reduce the risk of falls and injury.

C. Ensure the client knows to stop baclofen before using other antispasmodics: Baclofen should not be stopped abruptly due to the risk of withdrawal symptoms like hallucinations or seizures. Combining different antispasmodic medications can increase the risk of adverse effects such as excessive sedation or muscle weakness. Medication changes therefore should only be made under the supervision of the healthcare provider.

D. Monitor intake and output every 8 hours: Baclofen does not typically affect renal function or fluid balance significantly. Monitoring intake and output is not a standard intervention specific to baclofen administration unless there is another underlying condition.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The healthcare provider (HCP) prescribes pantoprazole for a client who experienced partial and full thickness burns. The client is questioning the nurse if this medication is necessary. Which action(s) should the nurse implement? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

The nurse is administering the muscle relaxant baclofen PO to a client diagnosed with multiple sclerosis. Which intervention should the nurse implement?

Correct Answer is B

Explanation

A client diagnosed with myasthenia gravis receives a prescription for pyridostigmine. Which intervention should the nurse implement when preparing to administer this medication?

The nurse is providing discharge instructions for a client with metastatic cancer who is prescribed morphine for bone pain. Which information from the client indicates to the nurse an understanding of the medication?

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