Patient Data
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"C"}}
Explanation
Blood glucose 218 mg/dL (12.1 mmol/L)
-
Classification: Unrelated Finding
-
Rationale: Minoxidil does not influence blood glucose levels. This elevated blood glucose is likely related to the patient’s known history of type 2 diabetes mellitus. It's not a side effect or intended therapeutic action of minoxidil.
Dizziness while sitting up
-
Classification: Nontherapeutic Side Effect
-
Rationale: Minoxidil is a vasodilator that can cause a rapid drop in blood pressure, particularly when changing positions (orthostatic hypotension). Dizziness is a common side effect due to decreased cerebral perfusion when blood pressure drops too quickly or too much.
Blood pressure 162/111 mm Hg
-
Classification: Therapeutic Result
-
Rationale: On admission, the patient’s BP was dangerously high at 203/166 mm Hg. A subsequent reading of 162/111 mm Hg shows a significant drop, indicating that minoxidil is having the desired therapeutic effect of lowering blood pressure, even though it's still above target.
Pain rated at 1 on a 0 to 10 scale
-
Classification: Unrelated Finding
-
Rationale: Minoxidil is not a pain medication and does not impact pain perception. A low pain score of 1 is likely due to an unrelated mild discomfort or pre-existing condition and has no connection to minoxidil's effects.
Urine output 600 mL
-
Classification: Unrelated Finding
-
Rationale: Minoxidil may cause fluid retention, but 600 mL urine output is within the normal range over a few hours (depending on timing and context). This measurement alone does not indicate a therapeutic or side effect of the drug, and without signs of oliguria or diuresis, it remains unrelated.
Correct Answer is A
Explanation
A. Hold one nostril closed while spraying the other nostril: Closing one nostril while administering the spray ensures the medication is delivered more effectively into the nasal passages, allowing for better absorption and symptom control by maximizing the contact of the medication with the nasal mucosa.
B. Use the inhaler when first awakening in the morning: The specific timing of intranasal corticosteroid use may vary depending on the healthcare provider's instructions and the client's symptom pattern. While morning use can be beneficial due to peak allergy symptoms, it is not the most critical technique instruction. Proper administration ensures better drug efficacy regardless of timing.
C. Avoid shaking the inhaler immediately before using: Some nasal sprays, especially suspensions, require shaking to evenly distribute the medication. Advising not to shake could lead to inconsistent dosing and reduced effectiveness, depending on the specific medication.
D. Angle the tip of the inhaler upward while spraying: The inhaler tip should be angled slightly outward toward the ear, not straight upward, to target the correct nasal structures. Spraying directly upward could lead to discomfort or less effective drug delivery.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.