A nurse in a clinic is collecting data from an adolescent who has type 1 diabetes mellitus.Which of the following findings is the priority for the nurse to report?
Client's current blood glucose is 220 mg/dL
Client is exhibiting Kussmaul respirations
Client reports vomiting once that day
Client reports frequent urination
The Correct Answer is B
Choice A reason:
A blood glucose level of 220 mg/dL is elevated and should be addressed, but it may not be an immediate priority compared to the presence of Kussmaul respirations.
Choice B reason.
Correct. Kussmaul respirations are a sign of diabetic ketoacidosis (DKA), a severe complication of diabetes. This requires immediate attention and intervention.
Choice C reason:
Vomiting is a concerning symptom, but it may not be as immediately life-threatening as Kussmaul respirations.
Choice D reason:
Frequent urination is a common symptom of diabetes, but it may not require immediate intervention unless it is accompanied by other severe symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Using a bleach-based solution to clean the bedside table is an appropriate measure to prevent the spread of Clostridium difficile bacteria, as bleach is effective in killing spores.
Choice B reason:
While hand sanitizer is useful for killing many types of bacteria and viruses, it may not be as effective against Clostridium difficile spores. Washing hands with soap and water is preferred.
Choice C reason:
Placing the toddler in a negative-airflow room is not necessary for managing Clostridium difficile diarrhea. Standard precautions and proper hygiene are sufficient.
Choice D reason:
Loperamide is not typically recommended for managing Clostridium difficile diarrhea, as it may worsen the condition by slowing down the bowel motility. The primary treatment is discontinuing the antibiotic that caused the infection and, in some cases, using specific antibiotics to target the C. difficile bacteria.
Correct Answer is B
Explanation
Choice A reason:
Encouraging fruit juices is not the best approach for rehydration in a child with mild dehydration. Fruit juices can be high in sugar and may worsen diarrhea.
Choice B reason:
Giving oral rehydration solution in small, frequent amounts is the recommended treatment for mild dehydration due to infection. This helps replace lost fluids and electrolytes.
Choice C reason:
Promethazine is not indicated for the treatment of dehydration. It is an antihistamine and antiemetic, but it does not address the underlying issue of fluid loss.
Choice D reason:
Offering banana and rice can be part of a bland diet after rehydration, but it does not address the immediate need for replenishing lost fluids and electrolytes. The priority is to start with oral rehydration solution.
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