Which intervention is most important for the nurse to implement for a client who is receiving insulin lispro?

Keep an oral liquid or glucose source available.

Provide meals at the same time this insulin is given.

Assess for hypoglycemia between meals.

Check blood glucose levels every six hours.

Answer and Explanation

The Correct Answer is B

Choice A reason: Keeping an oral liquid or glucose source available is a good intervention for any client who is receiving insulin, as it can help treat hypoglycemia, which is a low blood sugar level. However, it is not the most important intervention for a client who is receiving insulin lispro, which is a rapid-acting insulin that starts working within 15 minutes and lasts for 2 to 4 hours. The nurse should ensure that the client has a meal ready before giving this insulin, as it can cause severe hypoglycemia if the client does not eat soon after.

Choice B reason: Providing meals at the same time this insulin is given is the most important intervention for a client who is receiving insulin lispro, which is a rapid-acting insulin that mimics the natural insulin response to a meal. The nurse should coordinate the timing of the insulin injection and the meal, as the insulin will lower the blood sugar level quickly and the meal will provide the glucose needed to prevent hypoglycemia. The nurse should also teach the client and the family about the importance of eating within 15 minutes of taking this insulin.

Choice C reason: Assessing for hypoglycemia between meals is a good intervention for any client who is receiving insulin, as it can help detect and treat low blood sugar levels. However, it is not the most important intervention for a client who is receiving insulin lispro, which is a rapid-acting insulin that has a short duration of action. The risk of hypoglycemia is highest during the peak of the insulin action, which is 30 to 90 minutes after the injection. The nurse should monitor the client's blood sugar level more frequently during this time and provide snacks as needed.

Choice D reason: Checking blood glucose levels every six hours is not a sufficient intervention for a client who is receiving insulin lispro, which is a rapid-acting insulin that requires more frequent monitoring. The nurse should check the blood glucose level before each meal and at bedtime, as well as before and after exercise, to adjust the insulin dose and prevent hyperglycemia or hypoglycemia. The nurse should also teach the client and the family how to use a glucometer and record the blood glucose results.

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Correct Answer is B

Explanation

Choice A reason: This is not the correct time to collect the peak and trough levels. The peak level should be measured after the completion of the IV dose, not during the administration. The trough level should be measured just before the next administration, not 30 minutes before.

Choice B reason: This is the correct time to collect the peak and trough levels. The peak level should be measured one hour after the completion of the IV dose, when the concentration of the medication is highest in the blood. The trough level should be measured one hour before the next administration, when the concentration of the medication is lowest in the blood.

Choice C reason: This is not the correct time to collect the peak and trough levels. The peak level should be measured one hour after the completion of the IV dose, not two hours after. The trough level should be measured one hour before the next administration, not two hours before.

Choice D reason: This is not the correct time to collect the peak and trough levels. The peak level should be measured one hour after the completion of the IV dose, not immediately after. The trough level should be measured one hour before the next administration, not 30 minutes before.

A. Confirm that the daughter is aware of the progressive nature of the disease. B. Affirm the decision to use the medication when the symptoms start to worsen. C. Explain that the drug should be used early in the course of the disease process. D. Assess the client's current mental status before deciding to support the decision.

Correct Answer is C

Explanation

Choice A reason: Confirming that the daughter is aware of the progressive nature of the disease is not the best response, as it does not address the daughter's misconception about the drug. The nurse should educate the daughter that rivastigmine does not cure or stop the progression of Alzheimer's disease, but only slows down the cognitive decline.

Choice B reason: Affirming the decision to use the medication when the symptoms start to worsen is not appropriate, as it contradicts the evidence-based practice. The nurse should inform the daughter that rivastigmine is most effective when used in the early stages of Alzheimer's disease, as it can delay the need for institutionalization and improve the quality of life.

Choice C reason: Explaining that the drug should be used early in the course of the disease process is the best response, as it corrects the daughter's misunderstanding and provides accurate information. The nurse should explain that rivastigmine works by inhibiting the enzyme that breaks down acetylcholine, a neurotransmitter that is involved in memory and learning. By increasing the level of acetylcholine in the brain, rivastigmine can improve the cognitive function and behavior of the client.

Choice D reason: Assessing the client's current mental status before deciding to support the decision is not relevant, as it does not address the daughter's concern or the rationale for the drug. The nurse should already have the client's baseline mental status from the initial assessment and diagnosis. The nurse should focus on educating the daughter about the benefits and risks of rivastigmine and encouraging her to follow the prescribed regimen.

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Which intervention is most important for the nurse to implement for a client who is receiving insulin lispro?

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Explanation

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