The nurse cares for a client who is a pale and reports frequent fatigue, weakness and dizziness. Which serum laboratory test result is the nurse’s priority for planning care?

RBCs 4.3mEq/L

Potassium 4.8 mEq/L

Hemoglobin of 9g/dl

Sodium 137 mEq/L

Answer and Explanation

The Correct Answer is C

A) RBCs 4.3 million/µL:
While a low RBC count can indicate anemia, the specific value provided here is not suggestive of anemia, and it does not explain the patient's symptoms of fatigue, weakness, and dizziness as clearly as a low hemoglobin would.

B) Potassium 4.8 mEq/L:
This result is not concerning and does not directly relate to the patient's reported symptoms of pallor, fatigue, and dizziness. Therefore, this lab result does not take priority in planning care at this time.

C) Hemoglobin of 9 g/dl:
This result is consistent with anemia, which is a likely cause of the patient’s symptoms of fatigue, weakness, dizziness, and pallor. Anemia can lead to decreased oxygen delivery to tissues, explaining the symptoms the patient is experiencing. The priority action for the nurse should be to address the underlying cause of anemia and manage it to improve the patient’s oxygenation and overall condition.

D) Sodium 137 mEq/L:
Although sodium imbalances can cause neurological symptoms such as confusion or lethargy, the patient’s reported symptoms of pallor, fatigue, and dizziness are more likely related to anemia. Sodium is not the most urgent concern for this patient at the moment.

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Correct Answer is B

Explanation

A. 2-6 hours before meals:
This timeframe is too long for rapid-acting insulin like Lispro. Rapid-acting insulins, such as Lispro, begin to work quickly after administration, typically within 15 minutes, and peak around 1 to 2 hours after injection. Administering it 2-6 hours before meals would not align with the timing of food intake and would likely lead to hypoglycemia before the meal. Timing of rapid-acting insulin should be closer to the meal to match the rise in blood glucose levels that occurs after eating.

B. Lispro lasts 24 hours and does not have to be timed with meals:
This statement is incorrect. Lispro is a rapid-acting insulin, and its duration of action is much shorter than 24 hours, typically lasting about 3-5 hours. It is crucial to time the administration of Lispro with meals to match its peak action with the rise in blood glucose levels after eating. A long-acting insulin would be the type that lasts for 24 hours, but that is not the case with Lispro.

C. 15-30 minutes before meals:
Lispro is a rapid-acting insulin, and its onset of action occurs within 15 minutes after injection. It is most effective when administered within 15-30 minutes before the start of a meal, as it peaks in about 1-2 hours and works to regulate blood glucose levels during and after the meal. This timing ensures that insulin works in concert with the rise in blood glucose following food intake, helping prevent hyperglycemia.

D. 60 minutes before meals:
Administering Lispro 60 minutes before a meal is too early. Rapid-acting insulins, such as Lispro, begin working quickly and reach peak action within 1-2 hours. If administered too far in advance, there is a risk that the insulin may have peaked before the meal, leading to a potential drop in blood glucose levels before the meal is consumed. This could result in hypoglycemia. Therefore, administering it closer to the meal, within 15-30 minutes, is the optimal timing.

A. Having the patient splint their incision site when coughing and deep breathing B. Offering around the clock pain medication the immediate post operative phase C. Administering prescribed pre-operative antibiotics within 30-60 minutes of surgery. D. Performing the first dressing change on a new surgical site in the post operative setting

Correct Answer is C

Explanation

A. Having the patient splint their incision site when coughing and deep breathing:
While splinting the incision site can help alleviate pain and prevent strain on the surgical wound during coughing and deep breathing, it is not a primary intervention for preventing surgical site infection. Infection prevention is more directly related to sterile technique, antibiotic prophylaxis, and maintaining a clean environment around the wound. Splinting can support postoperative recovery, but it does not directly prevent infection.

B. Offering around the clock pain medication in the immediate post-operative phase:
Providing pain medication is important for patient comfort and to facilitate early mobilization after surgery. However, pain management does not directly prevent surgical site infections. The focus for infection prevention lies in maintaining sterility, administering antibiotics as prescribed, and appropriate wound care rather than pain control alone.

C. Administering prescribed pre-operative antibiotics within 30-60 minutes of surgery:
The administration of prophylactic antibiotics before surgery, typically within 30-60 minutes of the incision, is a primary intervention for preventing surgical site infections (SSIs). This timing ensures that the antibiotics are at therapeutic levels in the bloodstream when the surgical procedure begins, reducing the risk of introducing bacteria into the surgical site. This is a well-established guideline for infection prevention in surgical settings.

D. Performing the first dressing change on a new surgical site in the postoperative setting:
The first dressing change should generally be done by a healthcare professional using sterile technique. However, the timing and handling of the first dressing change are more related to wound care practices rather than a primary strategy for preventing infection. Infection prevention primarily involves proper antibiotic prophylaxis, maintaining a sterile field, and managing the surgical site during the early post-operative period. The first dressing change, while important for wound healing, is not the most immediate or primary intervention for preventing surgical site infection.

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The nurse cares for a client who is a pale and reports frequent fatigue, weakness and dizziness. Which serum laboratory test result is the nurse’s priority for planning care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning care for a client with type 1 diabetes mellitus. When planning administration for rapid-acting insulin Lispro, the nurse knows to administer it during which timeframe based on the onset of action?

Correct Answer is B

Explanation

The nurse identifies which of the following as one of the primary nursing interventions for preventing surgical site infection?

Correct Answer is C

Explanation

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