The nurse is giving sub-Q insulin. A major nursing responsibility prior to administration of this category of drugs is to:

double verify with a licensed personnel.

monitor intake and output.

assess vital signs.

give with orange juice to promote absorption.

Answer and Explanation

The Correct Answer is A

A. double verify with a licensed personnel: Insulin is a high-alert medication with a narrow therapeutic window and a significant risk of causing serious harm if dosed incorrectly, including severe hypoglycemia. Double verification with another licensed healthcare professional ensures accurate dosing and enhances patient safety.

B. monitor intake and output: Monitoring intake and output is important for assessing fluid balance and kidney function but does not directly influence the safe administration of insulin or prevent dosing errors related to blood glucose control.

C. assess vital signs: While vital signs such as heart rate and blood pressure are important in overall patient assessment, they do not directly prevent insulin administration errors or detect hypoglycemia before it occurs.

D. give with orange juice to promote absorption: Orange juice is used to treat hypoglycemia due to its sugar content but does not promote insulin absorption. Insulin absorption is primarily influenced by injection site and technique, not concurrent food or drink intake.

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Correct Answer is C

Explanation

A. Granulation tissue forming at the bottom of the wound: This is typical of healing by secondary intention, where the wound is left open to heal from the base upward through granulation tissue formation and contraction.

B. Wound is contaminated at the time of injury: Contamination increases the risk of infection and usually results in delayed healing or healing by secondary intention, requiring more extensive wound care.

C. Skin edges of the wound are sutured closed: Healing by first intention occurs when wound edges are closely approximated, such as with sutures or staples, allowing faster healing with minimal scarring and reduced infection risk.

D. Healing of the wound is prolonged: First intention wounds typically heal faster than wounds healing by secondary intention because there is less tissue loss, inflammation, and risk of complications like infection.

A. Open the airway using a jaw-thrust maneuver. B. Assess the use of accessory muscles and rate of respirations. C. Remove clothing for a thorough assessment. D. Assess blood pressure and heart rate. E. Perform a Glasgow Coma Scale assessment.

Correct Answer is A,B,D,E,C

Explanation

A. Open the airway using a jaw-thrust maneuver: The first priority in a primary survey is airway management, especially in trauma cases. The jaw-thrust technique is used to maintain cervical spine alignment while opening the airway.

B. Assess the use of accessory muscles and rate of respirations: After the airway is secured, breathing is assessed next. Observing for respiratory effort and accessory muscle use helps determine respiratory function and oxygenation needs.

D. Assess blood pressure and heart rate: The next priority is circulation, which involves checking for adequate perfusion. Vital signs like heart rate and blood pressure provide critical information about circulatory status.

E. Perform a Glasgow Coma Scale assessment: Once ABCs are stable, disability is assessed using neurological tools like the GCS to evaluate consciousness and identify any brain injury.

C. Remove clothing for a thorough assessment: Exposure is the last step in the primary survey. Clothing is removed to fully inspect for other injuries while maintaining temperature control to prevent hypothermia.

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The nurse is giving sub-Q insulin. A major nursing responsibility prior to administration of this category of drugs is to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a wound that is healing by first intention. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Using a prioritization framework, identify the sequence of actions the nurse should take. (Arrange the boxes by dragging them in the selected order of performance.)

Correct Answer is A,B,D,E,C

Explanation

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