A nurse is providing teaching for a client who has diabetes mellitus about the self-administration of insulin. The client has prescriptions for regular and NPH insulins. Which of the following statements by the client indicates an understanding of the teaching?
"I will store prefilled syringes in the refrigerator with the needle pointed downward."
"I will shake the NPH vial vigorously before drawing up the insulin."
"I will insert the needle at a 15-degree angle."
"I will draw up the regular insulin into the syringe first."
The Correct Answer is D
A) "I will store prefilled syringes in the refrigerator with the needle pointed downward.": While prefilled syringes should be stored in the refrigerator, they should actually be stored with the needle pointing upward. This prevents the insulin from settling at the needle end and ensures that the insulin is readily available for injection. This statement reflects a misunderstanding of proper storage techniques.
B) "I will shake the NPH vial vigorously before drawing up the insulin.": NPH insulin should be gently rolled between the palms rather than shaken vigorously. Shaking can cause air bubbles and damage the insulin. This statement indicates a lack of understanding of the proper technique for preparing NPH insulin.
C) "I will insert the needle at a 15-degree angle.": The correct angle for injecting insulin is typically 90 degrees (or 45 degrees for thin clients), not 15 degrees. This statement shows a misunderstanding of proper injection technique.
D) "I will draw up the regular insulin into the syringe first.": This statement indicates an understanding of the proper technique for mixing insulins. When using both regular and NPH insulins, the regular insulin should always be drawn up first to prevent contamination of the short-acting insulin with the longer-acting insulin. This response reflects correct knowledge regarding insulin administration.
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Correct Answer is ["A","B","C","D"]
Explanation
A) Place the client in an upright sitting position: This is the first step because it helps to lower blood pressure by promoting venous return and decreasing the effects of increased sympathetic activity associated with autonomic dysreflexia. Immediate positioning can alleviate acute symptoms and prevent further complications.
B) Confirm that the client's bladder is empty: After ensuring the client is positioned appropriately, the next step is to check for urinary retention, which is a common trigger for autonomic dysreflexia. If the bladder is full, it can exacerbate the condition, so emptying it is crucial.
C)Indicate the risk for autonomic dysreflexia in the client's medical record: While this step is important for ongoing patient care and documentation, it is not an immediate priority during an acute episode of autonomic dysreflexia. Documenting the risk should occur after addressing the client's immediate needs to ensure their safety and well-being
D)Administer an antihypertensive medication intravenously: If the client's blood pressure remains elevated after positioning and emptying the bladder, the next step is to provide pharmacological intervention. Administering an antihypertensive medication can help manage and stabilize the client's blood pressure effectively.
Correct Answer is C
Explanation
A) NG tube: A nasogastric (NG) tube is not typically required for a client with a seizure
disorder unless there are specific feeding or medication administration needs post-seizure. It is not standard equipment for seizure management.
B) Wrist restraints: While restraints may be used in some situations to prevent injury, they are not routinely placed in a seizure patient's room and could increase the risk of harm during a seizure. It is generally best to ensure a safe environment without restraints.
C) Oral airway: Having an oral airway available in the client's room is essential for managing airway patency during or after a seizure. It can help to maintain an open airway, especially if the client becomes unresponsive or is at risk of aspiration.
D) Tongue blade: Using a tongue blade to hold the mouth open during a seizure is not recommended, as it can cause injury to the client or the nurse. It's a common myth that it should be used to prevent biting the tongue, but doing so can lead to more harm than good