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:
Providing pain medication on a schedule is important for managing pain and ensuring the child's comfort, especially after a surgery involving peritonitis.
Choice B reason:
Contact isolation is not typically indicated for a child postoperative for appendicitis unless there is a specific infectious concern. It is not a routine intervention.
Choice C reason:
Offering clear liquids may be appropriate depending on the child's individual recovery and surgeon's orders. However, this should be determined on an individual basis and is not a standard postoperative intervention.
Choice D reason:
Maintaining strict bed rest may not be necessary for all children postoperative for appendicitis. Early mobilization and ambulation are often encouraged to promote recovery.
Correct Answer is C
Explanation
Choice A reason:
Wrapping the extremity loosely with an elastic bandage may provide support but is not specifically aimed at reducing swelling.
Choice B reason:
Applying warm compresses can be beneficial for some types of injuries, but for a sprained wrist, cold compresses are more effective in reducing swelling.
Choice C reason:
This statement is correct. Elevating the extremity above the level of the heart helps to reduce swelling by promoting venous return and reducing blood flow to the affected area.
Choice D reason:
Encouraging active range of motion may be important for rehabilitation, but it is not the initial intervention for minimizing swelling in the first 12 to 24 hours after a sprain.
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