The client is a 26-year-old female with acute appendicitis. She has a 12-year history of type 1 diabetes and no other significant medical history. The appendectomy was completed without Issue, and the client will be admitted to the surgical floor to recover.
The PN prepares to give 2 units of Insulin lispro.
What should the PN double-check with a second nurse?
Select all that apply.
The sliding scale insulin lispro order
The type of insulin to be administered
The insulin vial for color and clarity
The dose of insulin drawn up in the syringe
The expiration date on the insulin vial
The history and physical with the diabetes diagnosis listed
The insulin concentration
The site for the insulin administration
Correct Answer : C,D,E,G
The PN should double-check the following with a second nurse:
- The dose of insulin drawn up in the syringe: Double-checking the dose of insulin is essential to ensure the correct amount is being administered to the client.
- The insulin vial for color and clarity: Insulin should be clear and free of particles or discoloration. Checking the vial for any abnormalities ensures the integrity and quality of the insulin.
- The expiration date on the insulin vial: Insulin should not be used beyond its expiration date. Verifying the expiration date helps ensure that the insulin is still effective and safe for administration.
- The insulin concentration: Different concentrations of insulin are available, such as
U-100 and U-500. Double-checking the concentration ensures that the correct type of insulin is being administered.
It's important to note that the other options listed are not necessary for double-checking with a second nurse in this context:
- The sliding scale insulin lispro order: Sliding scale insulin is typically used to adjust insulin doses based on blood glucose levels. However, in this case, the given dose of 2 units of insulin lispro may be a specific prescription for the client's diabetes management and not related to the acute appendicitis.
- The type of insulin to be administered: The type of insulin, in this case, is specified as insulin lispro. Confirming the type of insulin is important, but it is not a part of the double-checking process since it is already specified.
- The history and physical with the diabetes diagnosis listed: The client's medical history and diabetes diagnosis are important aspects of their overall care but are not directly related to double-checking the administration of insulin.
- The site for insulin administration: The specific site for insulin administration may depend on the client's individual preference or medical condition, but it is not a part of the double-check process. The double-check is primarily focused on the accuracy of the medication itself.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is the correct answer, as it reflects the nurse's assessment of the injury and the appropriate action to take. The nurse should consider the mother's report of pain as a valid indicator of the severity of the injury, and should not dismiss or minimize it. The nurse should also observe the boy's arm and shoulder for any signs of fracture, dislocation, swelling, bruising, or deformity, and ask him to rate his pain on a scale of 0 to 10. The nurse should then decide whether to refer the boy to a physician or an emergency department for further evaluation and treatment.
Correct Answer is B
Explanation
In infants with heart failure, they may have difficulty feeding due to fatigue and increased work of breathing. Allowing the infant to rest before feeding helps conserve their energy and reduces the risk of excessive fatigue during feeding.
The other options are not appropriate interventions for this situation:
A.Weigh before and after feeding: Weighing before and after feeding is not necessary in this case unless specifically ordered by the healthcare provider. It is not directly related to the management of feeding an infant with heart failure.
C.Feed the infant when he cries: Feeding the infant solely based on crying may not be appropriate in this case. It is important to establish a feeding schedule and monitor the infant's signs of hunger and satiety to ensure adequate nutrition and prevent overfeeding.
D.Insert a nasogastric feeding tube: Inserting a nasogastric feeding tube should not be the first intervention unless there is a specific indication or order from the healthcare provider. In this scenario, the focus is on supporting oral feeding and allowing the infant to rest before feeding.
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