Podcast
Questions and Answers
Why is it essential for the nurse to review a client's medical record prior to administering insulin?
Why is it essential for the nurse to review a client's medical record prior to administering insulin?
- To update the client's emergency contact information.
- To identify any contraindications to the medication. (correct)
- To determine the client's preferred brand of insulin.
- To ensure the client's insurance covers the cost of insulin.
Which action should the nurse perform first when preparing to administer an insulin injection?
Which action should the nurse perform first when preparing to administer an insulin injection?
- Cleanse the injection site with antiseptic.
- Provide education about potential adverse effects.
- Confirm the client's allergy status. (correct)
- Draw up the insulin into the syringe.
What is the primary rationale for using an insulin syringe for insulin injections rather than a standard syringe?
What is the primary rationale for using an insulin syringe for insulin injections rather than a standard syringe?
- Insulin syringes prevent insulin from interacting with the syringe material.
- Insulin syringes allow for more accurate dosing of insulin units. (correct)
- Insulin syringes are pre-filled to reduce medication preparation time.
- Insulin syringes have a smaller gauge needle to minimize discomfort.
A nurse observes that a client is sweating, shaking and appears confused. What action should the nurse take first?
A nurse observes that a client is sweating, shaking and appears confused. What action should the nurse take first?
Why is it essential to inject air into the insulin vial before withdrawing the medication?
Why is it essential to inject air into the insulin vial before withdrawing the medication?
A nurse is preparing an insulin injection and notices air bubbles in the syringe. What is the most appropriate action?
A nurse is preparing an insulin injection and notices air bubbles in the syringe. What is the most appropriate action?
What is the primary reason for using the one-handed scoop method when recapping a needle?
What is the primary reason for using the one-handed scoop method when recapping a needle?
According to the content, what angle of insertion is generally recommended for subcutaneous insulin injections?
According to the content, what angle of insertion is generally recommended for subcutaneous insulin injections?
Why should a nurse avoid massaging the injection site after administering insulin?
Why should a nurse avoid massaging the injection site after administering insulin?
Which documentation element is especially important to include on the MAR after administering insulin?
Which documentation element is especially important to include on the MAR after administering insulin?
What action is most important for the nurse to take to ensure client safety before leaving the room after administering insulin?
What action is most important for the nurse to take to ensure client safety before leaving the room after administering insulin?
Which of the following actions would be considered outside the scope of practice for assistive personnel (AP)?
Which of the following actions would be considered outside the scope of practice for assistive personnel (AP)?
A nurse is preparing insulin for a client with a new order. What is the most important step to ensure the 'right medication' according to the rights of medication administration?
A nurse is preparing insulin for a client with a new order. What is the most important step to ensure the 'right medication' according to the rights of medication administration?
A nurse identifies a client with significant alterations in skin integrity at all available subcutaneous injection sites. What is the best action for the nurse to take?
A nurse identifies a client with significant alterations in skin integrity at all available subcutaneous injection sites. What is the best action for the nurse to take?
Which action best demonstrates the nurse utilizing the nursing process during insulin administration?
Which action best demonstrates the nurse utilizing the nursing process during insulin administration?
A client questions why the nurse is using an antiseptic wipe on the vial of insulin before drawing up the medication. Which response by the nurse is best?
A client questions why the nurse is using an antiseptic wipe on the vial of insulin before drawing up the medication. Which response by the nurse is best?
What is the rationale for using a firm, circular motion, moving outward from the center of the injection site when cleansing the skin?
What is the rationale for using a firm, circular motion, moving outward from the center of the injection site when cleansing the skin?
A nurse provides education to a client who is newly diagnosed with diabetes mellitus. What information is most essential to include regarding insulin administration?
A nurse provides education to a client who is newly diagnosed with diabetes mellitus. What information is most essential to include regarding insulin administration?
A nurse is interrupted while preparing an insulin injection. According to best practices, what should the nurse do?
A nurse is interrupted while preparing an insulin injection. According to best practices, what should the nurse do?
What is the rationale behind drawing up air into the syringe, equal to the prescribed dose of insulin, prior to injecting air into the insulin vial?
What is the rationale behind drawing up air into the syringe, equal to the prescribed dose of insulin, prior to injecting air into the insulin vial?
After administering insulin, a small amount of blood appears at the injection site. What is the appropriate nursing intervention?
After administering insulin, a small amount of blood appears at the injection site. What is the appropriate nursing intervention?
A nurse is preparing to administer insulin to a thin adult. What modification to the standard injection technique should the nurse consider?
A nurse is preparing to administer insulin to a thin adult. What modification to the standard injection technique should the nurse consider?
A nurse is administering insulin to a client and is unsure if the dose is correct. What is the priority action by the nurse?
A nurse is administering insulin to a client and is unsure if the dose is correct. What is the priority action by the nurse?
Which action is most important when storing multi-dose insulin vials?
Which action is most important when storing multi-dose insulin vials?
In what phase of the nursing process does the step of providing client education about a medication fall?
In what phase of the nursing process does the step of providing client education about a medication fall?
What is the primary reason for checking a client's MAR for recently used injection sites before administering insulin?
What is the primary reason for checking a client's MAR for recently used injection sites before administering insulin?
A nurse discovers that they administered the wrong dose of insulin to a client. What is the nurse's priority action?
A nurse discovers that they administered the wrong dose of insulin to a client. What is the nurse's priority action?
A client is scheduled to receive insulin at 0730. Due to other required tasks, the nurse can't administer the insulin until 0815. What is the most appropriate action by the nurse?
A client is scheduled to receive insulin at 0730. Due to other required tasks, the nurse can't administer the insulin until 0815. What is the most appropriate action by the nurse?
Which action is most appropriate when a client refuses their scheduled insulin injection?
Which action is most appropriate when a client refuses their scheduled insulin injection?
Prior to administering insulin, the nurse assesses the proposed injection site and notices a rash. What is the best action by the nurse?
Prior to administering insulin, the nurse assesses the proposed injection site and notices a rash. What is the best action by the nurse?
A nurse is preparing two different types of insulin in one syringe. What action is essential to perform before administering the injection?
A nurse is preparing two different types of insulin in one syringe. What action is essential to perform before administering the injection?
A client with diabetes is scheduled to have a computed tomography (CT) scan with contrast dye. The nurse anticipates which potential adjustment to the client's insulin regimen?
A client with diabetes is scheduled to have a computed tomography (CT) scan with contrast dye. The nurse anticipates which potential adjustment to the client's insulin regimen?
What nursing action is most important for the evaluation phase of insulin administration?
What nursing action is most important for the evaluation phase of insulin administration?
Before administering insulin, a nurse reviews the client's MAR and discovers that the client received an antacid 30 minutes prior. What is the rationale for the nurse to consider this finding?
Before administering insulin, a nurse reviews the client's MAR and discovers that the client received an antacid 30 minutes prior. What is the rationale for the nurse to consider this finding?
A nurse is providing discharge instructions to a client about insulin injections. What statement by the client indicates a need for further teaching?
A nurse is providing discharge instructions to a client about insulin injections. What statement by the client indicates a need for further teaching?
A client is prescribed insulin glargine and insulin lispro. How should the nurse instruct the client to administer these two types of insulin?
A client is prescribed insulin glargine and insulin lispro. How should the nurse instruct the client to administer these two types of insulin?
A practical nurse (PN) is about to administer insulin. What is the registered nurse's (RN) responsibility in this situation?
A practical nurse (PN) is about to administer insulin. What is the registered nurse's (RN) responsibility in this situation?
A nurse is preparing to administer insulin. Which action demonstrates adherence to the 'right route' of medication administration?
A nurse is preparing to administer insulin. Which action demonstrates adherence to the 'right route' of medication administration?
A nurse is reviewing a client's medical record before administering insulin. What information would be most important to identify a potential contraindication?
A nurse is reviewing a client's medical record before administering insulin. What information would be most important to identify a potential contraindication?
After injecting insulin, a nurse notices a small amount of clear fluid leaking from the injection site. What is the best initial action?
After injecting insulin, a nurse notices a small amount of clear fluid leaking from the injection site. What is the best initial action?
A nurse is preparing insulin. Why is it important to limit distractions during this process?
A nurse is preparing insulin. Why is it important to limit distractions during this process?
A nurse is selecting an insulin injection site for a client. What finding at a potential injection site would warrant choosing a different location?
A nurse is selecting an insulin injection site for a client. What finding at a potential injection site would warrant choosing a different location?
A nurse is teaching a client about insulin administration. What statement by the client indicates a good understanding of the teaching?
A nurse is teaching a client about insulin administration. What statement by the client indicates a good understanding of the teaching?
A nurse is preparing to administer insulin from a multi-dose vial. What step is essential to ensure the medication's continued safety and efficacy?
A nurse is preparing to administer insulin from a multi-dose vial. What step is essential to ensure the medication's continued safety and efficacy?
A newly diagnosed diabetic client is prescribed insulin. What education should the nurse prioritize for this client?
A newly diagnosed diabetic client is prescribed insulin. What education should the nurse prioritize for this client?
A nurse is preparing to administer insulin to a client and notes that the client is diaphoretic, confused, and shaky. What is the nurse's most appropriate next action?
A nurse is preparing to administer insulin to a client and notes that the client is diaphoretic, confused, and shaky. What is the nurse's most appropriate next action?
Flashcards
Insulin Administration Delegation
Insulin Administration Delegation
The RN can delegate insulin administration to a PN, but not to AP.
Verify client identification
Verify client identification
Ensures the correct procedure is performed on the right client.
Skin-cleansing antiseptic
Skin-cleansing antiseptic
Reduces the risk of infection during procedures.
Review Medical Record
Review Medical Record
Signup and view all the flashcards
Provide Privacy
Provide Privacy
Signup and view all the flashcards
Introduce Yourself
Introduce Yourself
Signup and view all the flashcards
Client Education
Client Education
Signup and view all the flashcards
Follow Medication Rights
Follow Medication Rights
Signup and view all the flashcards
Check Medication Label
Check Medication Label
Signup and view all the flashcards
Hypoglycemia Indications
Hypoglycemia Indications
Signup and view all the flashcards
Hyperglycemia Indications
Hyperglycemia Indications
Signup and view all the flashcards
Aseptic Technique
Aseptic Technique
Signup and view all the flashcards
Inject Air into Vial
Inject Air into Vial
Signup and view all the flashcards
Remove Air Bubbles
Remove Air Bubbles
Signup and view all the flashcards
Second Nurse Verification
Second Nurse Verification
Signup and view all the flashcards
Label Multidose Vial
Label Multidose Vial
Signup and view all the flashcards
Store Multidose Vial
Store Multidose Vial
Signup and view all the flashcards
Inject at Correct Angle
Inject at Correct Angle
Signup and view all the flashcards
Engage Safety Shield
Engage Safety Shield
Signup and view all the flashcards
Apply Gentle Pressure
Apply Gentle Pressure
Signup and view all the flashcards
Evaluate Medication Outcome
Evaluate Medication Outcome
Signup and view all the flashcards
Angle for Thin Adults/Children
Angle for Thin Adults/Children
Signup and view all the flashcards
Document Medication
Document Medication
Signup and view all the flashcards
Study Notes
- Clients with diabetes mellitus (DM) might need insulin injections to lower their blood glucose levels, administered into subcutaneous tissue.
- Registered nurses (RN) can delegate insulin administration to practical nurses (PN), but not to assistive personnel (AP) as it's beyond their function.
- Safe medication administration is crucial to prevent errors and harm.
- Best practices and facility policies for medication administration must be followed.
Skills and Nursing Process
- Step-by-step instructions are given based on best practice guidelines.
- Each step corresponds to a phase of the nursing process.
- The nursing process is continuous, so steps may move back and forth between phases.
Safety Considerations
- Check for allergies to prevent allergic reactions.
- Verify client identification to ensure the correct procedure on the correct client.
- Use standard and infection control precautions to prevent the transmission of infectious organisms.
- Follow the rights of medication administration to reduce medication errors:
- Right client
- Right medication
- Right dose
- Right route
- Right time
- Right documentation
- Other rights: assessment, evaluation, refusal, education
Equipment
- Nonsterile gloves and PPE (if indicated) are needed.
- The medication administration record (MAR) is needed.
- A facility-approved skin-cleansing antiseptic is requried.
- An insulin syringe with needle is necessary for accurate dosing.
- An insulin vial is needed.
General Steps Prior to Medication Administration
Step 1: Review the client’s medical record.
- Assessment/Data Collection:
- Allergies, medical history, medications, previous vital signs, lab values, provider’s prescription, and facility policies.
- Reviewing the client’s medical record identifies contraindications and validates the prescription.
- Reviewing the skill for administering medications will vary from facility to facility.
- It is the nurse's responsibility and duty to review the facility’s policy and procedure manual
Step 2: Obtain supplies.
- Planning:
- Ensures preparedness with clean, working supplies.
Step 3: Provide privacy as needed.
- Implementation:
- Maintains client confidentiality.
Step 4: Introduce yourself to the client.
- Implementation:
- Promotes a therapeutic nurse-client relationship.
Step 5: Perform hand hygiene and put on appropriate PPE if indicated.
- Implementation:
- Hand hygiene is an essential infection control measure.
- Standard precautions with gloves and PPE are necessary for potential contact with bodily fluids.
Step 6: Identify the client using two unique identifiers.
- Assessment/Data Collection:
- Ensures the procedure is performed on the correct client.
Step 7: Confirm the client’s allergy status.
- Assessment/Data Collection:
- Prevents allergic reactions.
Step 8: Provide client education.
- Implementation:
- Medication name and purpose
- Potential adverse effects
- Procedure for administration of the medication
- Verification of the client’s understanding and their right to refuse
- Education decreases anxiety and promotes the nurse-client relationship.
- Clients should be informed about the medication and potential adverse effects.
- Verbal consent is needed, respecting the client's right to refuse.
- Understanding should be verified.
Step 9: Follow the rights of medication administration.
- Implementation:
- Limit distractions and prepare medication for only one client at a time.
- Check the MAR against the provider’s prescription.
- Identify the client’s need for the medication, interactions, contraindications, adverse effects, safe dosing, and any age/condition considerations.
- Check the client’s MAR and remove the prescribed medication from the medication supply system.
- Compare the medication label against the MAR and check the expiration date of the medication.
- Perform dosage calculation if needed.
- Reduces the risk of medication errors.
- Interruptions correlate with the frequency and severity of errors.
Step-by-Step at the Client’s Bedside
Step 1: Gather all supplies and take medications to the client’s bedside at the correct time.
- Implementation:
- Ensures preparedness.
Step 2: Perform hand hygiene and put on appropriate PPE if indicated.
- Implementation:
- Prevents infection.
Step 3: Verify the client’s identification and scan the barcode on the client’s hospital ID bracelet per facility policy.
- Implementation:
- Ensures the right medication is given to the right person.
Step 4: Recheck the medication label against the MAR and scan the medication barcode per facility policy.
- Implementation:
- Reduces the risk of medication errors.
Step 5: Check pertinent findings with regard to the medication immediately prior to administering the medication (e.g., apical heart rate if administering digoxin). Evaluate the client for indications of an alteration in blood glucose level.
- Assessment/Data collection:
- Decreases the risk of harm.
- Hypoglycemia indications: sweating, shaking, clammy skin, lethargy, confusion, lightheadedness, dizziness, or nausea.
- Hyperglycemia indications: increased thirst and urination.
- The blood glucose level should be rechecked before administering insulin if any hypoglycemic manifestations are present.
Step 6: Review the MAR for recently used injection sites and select a different site.
- Assessment/Data/Collection:
- Minimizes injury to subcutaneous tissue.
Step 7: Clean the rubber top on the vial of insulin with an antimicrobial wipe and allow it to dry.
- Implementation:
- Aseptic technique reduces infection risk.
Step 8: Remove the cap from the insulin syringe. Pull back on the plunger to draw up an amount of air that is equal to the prescribed amount of insulin.
- Implementation:
- Adding air equalizes pressure for easy medication removal.
Step 9: While holding the vial on a flat surface, pierce the top of the vial in the center and inject the air into the space above the insulin.
- Implementation:
- Equalizes pressure for easy medication removal.
Step 10: With the needle still inserted into the vial, use both hands to invert the vial and syringe. Keep the tip of the needle below the fluid level.
- Implementation:
- Prevents air from entering the syringe.
Step 11: Hold the vial with one hand and use the other hand to draw up the prescribed amount of insulin. Keep the vial and syringe at eye level.
- Implementation:
- Maximizes visibility and ensures correct dosage.
Step 12: Remove any air bubbles in the syringe by firmly tapping on the barrel of the syringe. Then inject the air back into the vial.
- Implementation:
- Ensures correct dosage.
Step 13: Carefully remove the needle from the vial and replace the cap over the needle using the one-hand scoop method.
- Implementation:
- Reduces the risk of needlestick injuries.
Step 14: Follow facility policy to determine the need for verification of the medication dose with another nurse prior to administration.
- Implementation:
- Insulin is a high-alert medication.
- Many facilities require dual verification.
- Decreases the risk of medication errors.
Step 15: Label the multidose vial with the date and time opened, if applicable.
- Implementation:
- Prevents use beyond safe date.
Step 16: Store the multidose vial according to facility policy.
- Implementation:
- Maintains medication potency.
Step 17: Raise the bed to a comfortable height and position the client to expose the injection site while maintaining privacy.
- Implementation:
- Proper body mechanics prevent injury.
- Exposing only the injection site promotes client comfort.
Step 18: Evaluate the client for alterations in skin integrity at the chosen site. Then cleanse the area of the injection site with the skin-cleansing antiseptic, using a firm, circular motion, moving outward from the center of the injection site. Allow to fully dry.
- Assessment/Data Collection:
- Maintains skin integrity and prevents infection.
- Cleansing from the center outward moves microorganisms away.
Step 19: Remove the cap from the syringe.
- Implementation:
- Prepares for injection.
Step 20: Use the nondominant hand to gently pinch skin at the injection site, if needed. Hold the syringe in the dominant hand between the thumb and forefinger.
- Implementation:
- The American Diabetes Association states that the skin should be pinched when a longer needle (> 6.8 mm) is used. Otherwise, the skin should not be pinched.
- Using the dominant hand allows for better control.
Step 21: Quickly insert the needle into the injection site at a 45° to 90° angle, depending on the thickness of the client’s subcutaneous tissue. If the skin is pinched, release the skinfold once the needle is in the tissue.
- Implementation:
- Ensures injection into subcutaneous tissue.
- Injection into other tissues affects absorption.
Step 22: Use the nondominant hand to stabilize the syringe near the skin, while sliding the dominant hand to the end of the syringe. Depress the plunger, slowly injecting the insulin.
- Implementation:
- Provides better control.
- Depressing the plunger injects the insulin.
Step 23: Once insulin is injected, wait 5 seconds, and then withdraw the needle at the same angle as it was inserted.
- Implementation:
- Ensures the entire dose is injected.
- Prevents tissue damage.
Step 24: Engage the safety shield on the needle and discard the syringe in a sharps container.
- Implementation:
- Prevents needlestick injuries.
Step 25: If blood or clear fluid is present at injection site, apply gentle pressure with a gloved finger or gauze. Do not massage or rub the injection site.
- Implementation:
- Prevents leakage and ensures accurate dosage.
- Massaging alters absorption rate.
Step 26: Assist the client to a position of comfort.
- Implementation:
Step 27: Ensure client safety before leaving the room.
- Implementation:
- Reduces the risk of falls and injuries.
- Keep the call light and personal items within reach.
- Lower the bed to the lowest position with the brakes locked.
Step 28: Evaluate the outcome of the medication at the appropriate time frame.
- Evaluation:
- Ensures effectiveness and identifies adverse effects.
Client Considerations
- Inject at a 45° angle for very thin adults and most children.
- Ensures injection into subcutaneous tissue.
Interventions for Unexpected Outcomes
- Check blood glucose and follow facility guidelines if hypoglycemic manifestations are present.
- Hypoglycemia symptoms: sweating, shaking, clammy skin, lethargy, confusion, lightheadedness, dizziness, or nausea.
Documentation
- Accurately document on the MAR and medical record per facility policy:
- Date and time of administration
- Nurse’s initials and signature
- Medication, dose, and route
- Pertinent findings
- Client education
- Client response
- Unexpected outcomes and notification of provider
- Documentation is part of the implementation phase.
- Allows for immediate access of client data.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
Description
Learn about insulin injections for diabetes mellitus, focusing on who can administer them. Registered Nurses can delegate to Practical Nurses. Understand the nursing process behind safe medication administration and safety considerations.
