Difficulty: Medium
Average Score: 85%
Simulated
Passage / Scenario
Nurses Notes0730
Admitted the client. She is awake and alert. She rates her pain 2/10. Her pulses are equal bilaterally. Heart rate is 76 beats per minute, normal sinus rhythm. Her oxygen saturation is 100% on room air. She has a gauze dressing over her surgical site, which is clean and dry. Her temperature is 98.5° F (37° C).
She urinated 50 ml upon arrival in the unit and is stating she is very thirsty. The patient states her last insulin glargine dose was this morning before surgery.
Orders
ÔÇó Admit to the surgical floor
ÔÇó Dextrose 5% and 0.9% sodium chloride to infuse at 125 mL/hr
ÔÇó Advance diet as tolerated
ÔÇó Insulin glargine 12 units subcutaneously every 12 hours
ÔÇó Ceftriaxone 2 g IV every 24 hours for 3 days, first dose given in surgery
ÔÇó Insulin lispro 1 unit subcutaneously per 15 carbohydrates
The nurse prepares to give 2 units of insulin lispro. What should the nurse double-check with a second nurse? Select all that apply.
Correct answer
A,C,E,G
Rationale
Double-checking the vialÔÇÖs color/clarity ensures insulin stability, the dose in the syringe prevents errors, the expiration date confirms potency, and the concentration (e.g., U-100) ensures accurate dosing. History, sliding scale, and injection site do not require dual verification.