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 C

Explanation

Choice A reason: Administering both prescribed medications as scheduled is not the appropriate action in this situation. The client's total calcium level is above the normal range of 9 to 10.5 mg/dL (2.25 to 2.62 mmol/L), indicating hypercalcemia. Hypercalcemia is a serious condition that can cause nausea, vomiting, constipation, confusion, kidney stones, and cardiac arrhythmias. Giving more calcitriol and calcium carbonate would worsen the client's condition and increase the risk of complications.

Choice B reason: Holding the calcium carbonate, but administering the calcitriol as scheduled is not the appropriate action in this situation. Calcium carbonate is a supplement that provides extra calcium to the body. Calcitriol is a synthetic form of vitamin D that helps the body absorb calcium from the intestines and kidneys. Both medications can increase the blood calcium level and cause hypercalcemia. The nurse should not give either medication without consulting the healthcare provider.

Choice C reason: Holding both medications until contacting the healthcare provider is the best action in this situation. The nurse should recognize that the client's total calcium level is dangerously high and report it to the healthcare provider as soon as possible. The healthcare provider may order to stop or adjust the doses of calcitriol and calcium carbonate, and prescribe other treatments to lower the blood calcium level, such as intravenous fluids, diuretics, or bisphosphonates.

Choice D reason: Holding the calcitriol, but administering the calcium carbonate as scheduled is not the appropriate action in this situation. Calcium carbonate is a supplement that provides extra calcium to the body. Giving more calcium carbonate to a client with hypercalcemia would increase the blood calcium level even more and cause more harm. The nurse should not give any medication that can raise the blood calcium level without consulting the healthcare provider.

A. Serum ammonia level of 30 Mcg/dL (17.62 mmol/L). B. Hemoglobin level of 13.5 g/dL (135 g/L). C. Serum potassium level of 3.8 mEq/L (3.8 mmol/L). D. Serum glucose level of 120 mg/dL (6.7 mmol/L).

Correct Answer is C

Explanation

Choice A reason: This is not the laboratory finding that indicates that the medication has been effective. Serum ammonia level of 30 Mcg/dL (17.62 mmol/L) is within the normal range for adults, and it does not reflect the effect of sodium polystyrene sulfonate. Sodium polystyrene sulfonate is a cation-exchange resin that binds to potassium in the intestine and removes it from the body through the stool. It does not affect the ammonia levels in the blood, which are influenced by the liver function and the urea cycle. The nurse should monitor the ammonia levels for any changes, but it is not the goal of the medication.

Choice B reason: This is not the laboratory finding that indicates that the medication has been effective. Hemoglobin level of 13.5 g/dL (135 g/L) is within the normal range for females, and it does not reflect the effect of sodium polystyrene sulfonate. Sodium polystyrene sulfonate does not affect the hemoglobin levels in the blood, which are determined by the number and size of red blood cells and the oxygen-carrying capacity of the blood. The nurse should monitor the hemoglobin levels for any changes, but it is not the goal of the medication.

Choice C reason: This is the laboratory finding that indicates that the medication has been effective. Serum potassium level of 3.8 mEq/L (3.8 mmol/L) is within the normal range for adults, and it indicates that the medication has lowered the potassium levels in the blood. Sodium polystyrene sulfonate is used to treat hyperkalemia, or high potassium levels, which can occur in AKI due to the impaired renal excretion of potassium. Hyperkalemia can cause cardiac arrhythmias, muscle weakness, and paralysis. The nurse should administer sodium polystyrene sulfonate as prescribed and check the serum potassium levels regularly to ensure that they are within the normal range.

Choice D reason: This is not the laboratory finding that indicates that the medication has been effective. Serum glucose level of 120 mg/dL (6.7 mmol/L) is slightly above the normal range for adults, and it does not reflect the effect of sodium polystyrene sulfonate. Sodium polystyrene sulfonate does not affect the glucose levels in the blood, which are influenced by the carbohydrate metabolism and the insulin secretion and action. The nurse should monitor the glucose levels for any changes, but it is not the goal of the medication.

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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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