The nurse is preparing to administer Regular insulin to a client with a blood glucose of 265. What action should the nurse take to determine the correct dose?
Review the patient’s previous blood glucose levels
No review is necessary before administering insulin
Review the Regular insulin sliding scale for administration in the patient’s electronic medical record
Review the patient’s previous insulin administration doses
The Correct Answer is C
Choice A reason: This is incorrect. Reviewing the patient’s previous blood glucose levels may not be helpful in determining the correct dose of insulin, as the blood glucose level can fluctuate depending on various factors, such as food intake, activity, stress, and illness. The previous blood glucose levels may not reflect the current insulin needs of the patient¹.
Choice B reason: This is incorrect. No review is not an option before administering insulin, as insulin is a highalert medication that can cause serious harm if given incorrectly. The nurse should always check the patient’s blood glucose level, the insulin order, the insulin type, the insulin dose, the insulin expiration date, and the insulin injection site before giving insulin.
Choice C reason: This is correct. Reviewing the Regular insulin sliding scale for administration in the patient’s electronic medical record is the best action to determine the correct dose of insulin. A sliding scale is a chart of insulin dosages based on blood glucose level and mealtime. It is used to adjust the insulin dose according to the patient’s blood glucose level and insulin sensitivity. The nurse should follow the sliding scale protocol and verify the insulin dose with another nurse before administering it.
Choice D reason: This is incorrect. Reviewing the patient’s previous insulin administration doses may not be helpful in determining the correct dose of insulin, as the insulin dose may vary depending on the patient’s blood glucose level and insulin sensitivity. The previous insulin doses may not reflect the current insulin needs of the patient¹.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A reason: This is correct. Dry mouth is a common side effect of anticholinergic drugs. It occurs because anticholinergic drugs block the action of acetylcholine, a neurotransmitter that stimulates the secretion of saliva and other fluids in the body. Dry mouth can cause discomfort, bad breath, and increased risk of dental problems¹.
Choice B reason: This is incorrect. Constricted bronchioles are not a side effect of anticholinergic drugs. In fact, anticholinergic drugs can cause the opposite effect: dilated bronchioles. This is because anticholinergic drugs block the action of acetylcholine, a neurotransmitter that causes the smooth muscles of the airways to contract. Dilated bronchioles can improve breathing and reduce wheezing in people with respiratory disorders, such as asthma or COPD.
Choice C reason: This is incorrect. Increased heart rate is not a side effect of anticholinergic drugs. In fact, anticholinergic drugs can cause the opposite effect: decreased heart rate. This is because anticholinergic drugs block the action of acetylcholine, a neurotransmitter that slows down the heart rate and lowers the blood pressure. Decreased heart rate can be beneficial for people with certain heart conditions, such as atrial fibrillation or tachycardia.
Choice D reason: This is correct. Dilated pupils are a common side effect of anticholinergic drugs. It occurs because anticholinergic drugs block the action of acetylcholine, a neurotransmitter that controls the muscles of the iris, which regulate the size of the pupils. Dilated pupils can cause blurred vision, sensitivity to light, and difficulty focusing.
Correct Answer is C
Explanation
Choice A reason: This is incorrect. Miosis is the constriction of the pupils, which can also be caused by morphine, but it is not a life-threatening side effect. Miosis occurs because morphine stimulates the parasympathetic nervous system, which controls the muscles that constrict the pupils¹.
Choice B reason: This is incorrect. Sedation is the state of being calm, relaxed, and sleepy, which can also be caused by morphine, but it is not a life-threatening side effect. Sedation occurs because morphine depresses the central nervous system, which reduces the activity of the brain and the body.
Choice C reason: This is correct. Respiratory depression is the slowing down of breathing, which can be a life-threatening side effect of morphine. Respiratory depression occurs because morphine depresses the respiratory center in the brainstem, which regulates the rate and depth of breathing. If the breathing becomes too slow or shallow, the patient may not get enough oxygen and may lose consciousness or die.
Choice D reason: This is incorrect. Euphoria is the feeling of intense happiness, pleasure, or wellbeing, which can also be caused by morphine, but it is not a life-threatening side effect. Euphoria occurs because morphine stimulates the reward system in the brain, which releases dopamine, a neurotransmitter that causes positive emotions.
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