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.
Nursing Test Bank
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 D
Explanation
A) Hypertension: Phenytoin is primarily used to manage seizures, and hypertension is not a common side effect associated with its use. While monitoring blood pressure is important for overall health, it is not specifically indicated for detecting common side effects of phenytoin.
B) Peripheral edema: Peripheral edema is not a typical side effect of phenytoin. Common side effects are usually related to oral health and skin changes rather than fluid retention or swelling in the extremities.
C) Hematuria: Hematuria, or blood in the urine, is not commonly associated with phenytoin use. This side effect is more relevant to other medications or conditions, and while monitoring for overall health changes is important, it is not a primary concern with phenytoin.
D) Gingival hyperplasia: Phenytoin is well-known for causing gingival hyperplasia, which is the overgrowth of gum tissue. This is a common and notable side effect of long-term phenytoin use, making it important for the nurse to assess for this symptom in clients receiving the medication.
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