A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus. Which of the following statements from the client indicates to the nurse the teaching is effective?
“I will freeze unopened insulin vials.”.
“I should increase my insulin when I exercise.”.
“I should inject the insulin into my abdominal area.”.
“I will shake the insulin vial vigorously to mix.”.
The Correct Answer is C
Choice A rationale
Freezing unopened insulin vials is incorrect. Insulin should be stored in the refrigerator at a temperature between 36°F and 46°F (2°C and 8°C) until it is opened. Freezing insulin can cause it to lose its potency and effectiveness. Once opened, insulin vials can be kept at room temperature for up to 28 days, but they should never be frozen.
Choice B rationale
Increasing insulin when exercising is incorrect. Exercise generally lowers blood glucose levels, so clients with type 1 diabetes may need to decrease their insulin dose or consume additional carbohydrates to prevent hypoglycemia during and after physical activity. It is important for clients to monitor their blood glucose levels closely and adjust their insulin and carbohydrate intake accordingly.
Choice C rationale
Injecting insulin into the abdominal area is correct. The abdominal area is one of the recommended sites for insulin injection because it has a large surface area and provides consistent absorption. Other recommended sites include the upper outer arms, thighs, and buttocks. Rotating injection sites within the same area helps prevent lipodystrophy and ensures better insulin absorption.
Choice D rationale
Shaking the insulin vial vigorously to mix is incorrect. Insulin vials should be gently rolled between the hands to mix the contents. Shaking the vial vigorously can cause air bubbles to form, which can lead to inaccurate dosing. Proper mixing ensures that the insulin is evenly distributed and effective.
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Correct Answer is ["B","D","E"]
Explanation
Choice A rationale
Contacting the surgeon if the client reports a continual need to void is not necessary unless it is accompanied by other symptoms such as pain or discomfort. The sensation of needing to void can be common after a TURP due to the presence of the catheter and bladder irrigation. This sensation usually resolves as the bladder heals and adjusts to the catheter.
Choice B rationale
Using sterile technique when preparing the irrigation solution is crucial to prevent infection. Sterile technique ensures that no pathogens are introduced into the bladder, which could lead to complications such as urinary tract infections or sepsis. Maintaining a sterile environment is a fundamental aspect of postoperative care, especially when dealing with invasive procedures like TURP.
Choice C rationale
Adding the amount of bladder irrigation to the total output is incorrect. The correct practice is to subtract the amount of irrigation solution used from the total output to determine the actual urine output. This helps in accurately monitoring the client’s fluid balance and kidney function. Incorrectly adding the irrigation amount could lead to misinterpretation of the client’s urinary output and fluid status.
Choice D rationale
Notifying the surgeon if the urine is bright red or has large clots is essential. Bright red urine or large clots can indicate active bleeding, which is a potential complication after TURP. Early detection and intervention are crucial to prevent significant blood loss and other complications. The nurse should monitor the urine color and consistency closely and report any abnormalities immediately.
Choice E rationale
Ensuring the drainage tubing is patent and without obstruction is vital for the effectiveness of continuous bladder irrigation. Obstructions in the tubing can lead to bladder distention, discomfort, and potential damage to the bladder and urethra. Regularly checking the tubing for kinks or blockages and ensuring a free flow of irrigation solution helps maintain proper bladder function and prevent complications.
Correct Answer is D
Explanation
Choice A rationale
While feeling depressed is a significant concern, it is not the highest priority in the context of systemic lupus erythematosus (SLE). Depression should be addressed, but it does not pose an immediate threat to the client’s physical health.
Choice B rationale
Joint pain in hands and knees is a common symptom of SLE but is not the highest priority. It indicates inflammation but does not pose an immediate risk to the client’s overall health.
Choice C rationale
A dry, raised rash on the face, often referred to as a “butterfly rash,” is a characteristic symptom of SLE. However, it is not the highest priority to report as it does not pose an immediate threat.
Choice D rationale
Presence of peripheral edema is the highest priority to report because it can indicate kidney involvement, which is a serious complication of SLE. Kidney damage can lead to significant health issues and requires immediate attention.