A nurse is caring for a client who has type 1 diabetes mellitus and a capillary blood glucose reading of 48 mg/dL. Which of the following findings should the nurse expect?

Choice A reason: Maintaining the client's head of the bed at 20% is an incorrect action, because the head of the bed should be elevated at least 30% to prevent aspiration of the feeding.

Choice B reason: Monitoring the client’s blood glucose level is a correct action, because enteral feedings can affect the blood glucose level and the client may need insulin adjustments.

Choice C reason: Flushing the enteral feeding tube with 10 mL of cool water after each medication is an incorrect action, because cool water can cause cramping and nausea. The nurse should use warm water to flush the tube and use at least 30 mL of water to prevent clogging.

Choice D reason: Obtaining an x-ray after beginning the feeding is an incorrect action, because an x-ray should be obtained before starting the feeding to confirm the placement of the tube.

Choice A reason: This is a nonspecific finding, because a report of a severe headache can be caused by many factors, such as concussion, migraine, or tension. A headache alone is not an indication of a skull fracture.

Choice B reason: This is a specific finding, because clear fluid coming from the nares can indicate a cerebrospinal fluid (CSF) leak, which is a sign of a basilar skull fracture. CSF is the fluid that surrounds and protects the brain and spinal cord, and can leak through the nose or ears if the skull is fractured.

Choice C reason: This is a nonspecific finding, because a brief change in level of consciousness can be caused by many factors, such as hypoxia, hypoglycemia, or seizure. A change in level of consciousness alone is not an indication of a skull fracture.

Choice D reason: This is a nonspecific finding, because bleeding from the top of the scalp can be caused by many factors, such as laceration, abrasion, or contusion. Bleeding from the scalp alone is not an indication of a skull fracture.