The nurse is caring for a client receiving regular insulin prescribed per a sliding scale. If a dose of regular insulin is administered at 0730, which additional nursing action is indicated for this client?

Ensure that the client eats breakfast.

Provide a mid-afternoon snack for the client.

Assess the client for hypoglycemia around 1500.

Perform a glucometer reading at 1000.

Answer and Explanation

The Correct Answer is A

A. Ensure that the client eats breakfast: Regular insulin is a fast-acting insulin that typically begins to work within 30 minutes to an hour after administration, peaks around 2-3 hours, and can last for up to 6 hours. Therefore, it is crucial that the client eats a meal, such as breakfast, shortly after the insulin is administered to prevent hypoglycemia.
B. Provide a mid-afternoon snack for the client: While snacks may be necessary depending on the client's overall meal and insulin schedule, it is more critical to ensure the client eats the meal immediately following insulin administration to manage blood glucose levels.
C. Assess the client for hypoglycemia around 1500: While monitoring for hypoglycemia is important, it is more critical to ensure the client eats their meal soon after insulin administration to prevent hypoglycemia in the first place.
D. Perform a glucometer reading at 1000: A glucometer reading at 1000 might be useful for monitoring blood glucose levels but ensuring that the client eats a meal promptly is a more immediate and critical action following insulin administration.

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Correct Answer is D

Explanation

A. Instruct the client that since the hematocrit remains low, the daily injections are still necessary: A hematocrit of 43% is within the normal range, suggesting the client’s anemia is improving. If the hematocrit were still low, continuing daily injections would be appropriate, but this is not the case here.

B. Notify the healthcare provider of the client’s hematocrit level so the frequency of injections can be reduced: Since the hematocrit is normal, there is no need to notify the healthcare provider specifically for changing the injection frequency based solely on the hematocrit level. Reducing injection frequency should be based on the overall treatment plan and not just the current hematocrit.
C. Advise the client that the medication is having the desired effect, but daily injections will continue to be needed for life for this chronic condition: While the medication may be effective, informing the client about the potential for less frequent injections could improve adherence and reduce discomfort, if the healthcare provider approves.
D. Offer to instruct the client in self-administration techniques to improve the client's sense of control over the painful daily injections: Teaching self-administration can empower the client and potentially reduce discomfort by allowing the client to become more comfortable with the process. It also offers the opportunity for the client to manage their injections more conveniently and with greater control.

A. "I need to notify my healthcare provider if I lose my appetite or get nauseated." B. "I should take my furosemide only if I have shortness of breath or swelling in my feet." C. "I need to check my blood pressure three times a day." D. "If I lose more than one pound in a week, I should hold my next dose of furosemide."

Correct Answer is A

Explanation

A. "I need to notify my healthcare provider if I lose my appetite or get nauseated." This statement shows understanding because loss of appetite and nausea can be symptoms of digoxin toxicity or side effects, and it is important to report these symptoms to a healthcare provider. Monitoring for such side effects is crucial when taking digoxin.
B. "I should take my furosemide only if I have shortness of breath or swelling in my feet." This statement is incorrect because furosemide, a diuretic, should be taken according to the prescribed schedule, not based on symptoms. It is used to manage fluid retention and symptoms of heart failure, and its use should not be dependent solely on the presence of symptoms.
C. "I need to check my blood pressure three times a day." While monitoring blood pressure is important, it is not specifically required for patients on digoxin and furosemide unless instructed by a healthcare provider. The focus should be more on monitoring for symptoms of drug side effects and electrolyte imbalances.
D. "If I lose more than one pound in a week, I should hold my next dose of furosemide." Weight loss can be a normal effect of furosemide due to fluid loss, and the decision to hold a dose should be based on specific medical advice and not solely on weight change.

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The nurse is caring for a client receiving regular insulin prescribed per a sliding scale. If a dose of regular insulin is administered at 0730, which additional nursing action is indicated for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Digoxin and furosemide were prescribed for a client with chronic heart failure, and the home health nurse is evaluating the client's self-care knowledge of these drugs. Which statement indicates that the client has a good understanding about the use of these drugs?

Correct Answer is A

Explanation

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