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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
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.
Correct Answer is A
Explanation
A. Advise the client that the healthcare provider needs to be made aware of the current diet: This is the most appropriate response. Warfarin is an anticoagulant that works by inhibiting vitamin K, which is essential for blood clotting. Leafy green vegetables, such as spinach and kale, are high in vitamin K and can interfere with the effectiveness of warfarin. It is important for the healthcare provider to be aware of the client’s diet to properly adjust the warfarin dosage and ensure effective anticoagulation while minimizing the risk of bleeding or clotting.
B. Suggest that the client replace the leafy vegetables with a protein source such as nuts or beans: This suggestion is not necessary unless there are specific dietary restrictions. While it's true that leafy green vegetables can affect warfarin, replacing them with other foods is not required. It’s more important to manage vitamin K intake consistently.
C. Confirm that the client’s diet choices will help the medication be more effective in preventing blood clots: This statement is incorrect. Leafy green vegetables can counteract the effects of warfarin due to their high vitamin K content.
D. Commend the patient for a healthy lifestyle and encourage the client to continue current diet habits: Although a diet rich in vegetables is generally healthy, it’s crucial to recognize that the high vitamin K content can impact the effectiveness of warfarin therapy. Therefore, simply encouraging the client to continue the current diet without considering its interaction with the medication is not appropriate
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