The patient received Humalog (rapid acting) insulin 5 units subcutaneously at 8:00 AM. The nurse plans to monitor this patient for signs of hypoglycemia at which time related to the insulin's peak action?
1:00 PM
8:00 PM
There is no peak action for this insulin
9:00 AM
The Correct Answer is D
Choice A reason: 1:00 PM is not the correct time to monitor the patient for signs of hypoglycemia related to the insulin's peak action. Humalog is a rapid acting insulin that starts to work within 15 minutes, peaks in about an hour, and lasts for 2 to 4 hours. Therefore, the peak action of Humalog given at 8:00 AM would be around 9:00 AM, not 1:00 PM.
Choice B reason: 8:00 PM is also not the correct time to monitor the patient for signs of hypoglycemia related to the insulin's peak action. As explained in choice A, Humalog peaks in about an hour and lasts for 2 to 4 hours. Therefore, the effect of Humalog given at 8:00 AM would wear off by 12:00 PM, not 8:00 PM.
Choice C reason: There is no peak action for this insulin is an incorrect statement. Humalog does have a peak action, as described in choice A. The peak action of an insulin is the time when the insulin is most effective in lowering the blood glucose level. The peak action of an insulin can vary depending on the type, dose, and individual response of the patient.
Choice D reason: 9:00 AM is the correct time to monitor the patient for signs of hypoglycemia related to the insulin's peak action. Hypoglycemia is a condition of low blood glucose level, which can cause symptoms such as sweating, shaking, hunger, headache, dizziness, confusion, and loss of consciousness. Hypoglycemia can occur when the insulin dose is too high, the food intake is too low, or the physical activity is too high. The nurse should monitor the patient for signs of hypoglycemia around the peak action of the insulin, as this is when the blood glucose level is most likely to drop. The nurse should also teach the patient how to prevent, recognize, and treat hypoglycemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This statement is false. Nephropathy is a term that refers to any disease or damage of the kidneys. Acetaminophen overdose can cause nephropathy, but it is not the most serious toxic effect. Nephropathy can manifest as reduced urine output, increased blood urea nitrogen and creatinine levels, and electrolyte imbalance.
Choice B reason: This statement is false. Tachycardia is a term that refers to a fast heart rate, usually more than 100 beats per minute. Acetaminophen overdose can cause tachycardia, but it is not the most serious toxic effect. Tachycardia can be a sign of dehydration, fever, pain, or anxiety.
Choice C reason: This statement is true. Liver dysfunction is the most serious toxic effect of acute acetaminophen overdose. Acetaminophen is metabolized by the liver and can produce a toxic byproduct that damages the liver cells. Liver dysfunction can manifest as jaundice, abdominal pain, nausea, vomiting, and elevated liver enzymes.
Choice D reason: This statement is false. Central nervous system depression is a term that refers to a reduced level of consciousness, alertness, and responsiveness. Acetaminophen overdose can cause central nervous system depression, but it is not the most serious toxic effect. Central nervous system depression can be a sign of hypoxia, hypoglycemia, or drug intoxication.
Correct Answer is D
Explanation
Choice A reason: Performing an in/out catheterization is not a suitable method to measure urine output for a 10-month old client with dehydration. An in/out catheterization is a procedure where a catheter is inserted into the bladder through the urethra, and the urine is drained and measured. This method is invasive, painful, and carries the risk of infection and trauma. It is usually reserved for clients who have urinary retention or obstruction, or who need a sterile urine sample.
Choice B reason: Inserting a Foley catheter is also not an appropriate method to measure urine output for a 10-month old client with dehydration. A Foley catheter is a type of catheter that stays in the bladder and drains the urine into a collection bag. This method is also invasive, painful, and carries the risk of infection and trauma. It is usually used for clients who have urinary incontinence, surgery, or long-term bed rest.
Choice C reason: Collecting the client's urine in a cup is not a feasible method to measure urine output for a 10-month old client with dehydration. A cup is not a reliable or accurate device to collect and measure urine, especially for a young child who may not be toilet trained or cooperative. It is also difficult to ensure that all the urine is collected in the cup, and that the cup is not contaminated by other fluids or substances.
Choice D reason: Counting the number of wet diapers is the best method to measure urine output for a 10-month old client with dehydration. This method is non-invasive, simple, and practical. It can provide an estimate of the urine volume and frequency, and indicate the hydration status of the child. The nurse should weigh the diapers before and after use, and record the difference in grams. One gram of weight equals one milliliter of urine. The nurse should also observe the color, odor, and concentration of the urine. The normal urine output for a child is 1 to 2 mL/kg/hour.
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