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 B
Explanation
Choice A reason:
Administering naloxone is not indicated for a seizure. Naloxone is used to reverse opioid overdose, not treat seizures.
Choice B reason:
Checking inside the child's mouth for bleeding is important after a seizure to ensure there is no injury to the oral cavity.
Choice C reason:
Giving the child a drink of water immediately after a seizure is not a priority intervention. The child may not be able to swallow properly immediately after a seizure.
Choice D reason:
Placing the child's head in a hyperextended position is not a recommended intervention after a seizure. It is important to maintain the child in a safe position and provide appropriate care after the seizure has ended.
Correct Answer is C
Explanation
Choice A reason:
Collecting a stool specimen for occult blood is not the most relevant test for suspected
Clostridium difficile infection. Stool culture or testing for C. difficile toxins is more appropriate.
Choice B reason:
Conducting a tape test is used to diagnose pinworms, not Clostridium difficile infection.
Choice C reason:
This statement is correct. Obtaining a stool specimen for culture, specifically for C. difficile, is the appropriate action for suspected infection.
Choice D reason:
Drawing a blood culture is not the primary diagnostic test for Clostridium difficile. Stool culture or testing for C. difficile toxins is more appropriate.
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