A nurse is collecting data from a child who has type 1 diabetes mellitus and has slurred speech, is diaphoretic, and has a blood glucose reading of 45 mg/dL. Which of the following should the nurse administer?
Insulin.
Metformin.
6 oz diet soft drink.
6 oz regular soft drink.
The Correct Answer is D
Choice A rationale:
Insulin administration is not appropriate in this situation. The child's symptoms (slurred speech, diaphoresis, low blood glucose reading) indicate hypoglycemia, which is a state of low blood sugar. Administering insulin, which lowers blood glucose further, would exacerbate the hypoglycemia and could lead to more severe symptoms or even unconsciousness.
Choice B rationale:
Metformin is not indicated in this scenario. Metformin is an oral medication used to treat type 2 diabetes, not type 1 diabetes mellitus. The child in the scenario has type 1 diabetes, which is characterized by an absolute deficiency of insulin production.
Choice C rationale:
Offering a 6 oz diet soft drink is not the appropriate intervention for hypoglycemia. Diet soft drinks do not contain significant amounts of sugar, which is needed to rapidly raise the child's blood glucose levels. In cases of hypoglycemia, a source of quickly absorbable sugar, such as a regular soft drink or fruit juice, is recommended.
Choice D rationale:
Administering a 6 oz regular soft drink is the appropriate intervention in this situation. The child is experiencing hypoglycemia, which means their blood glucose levels are dangerously low. Regular soft drinks contain rapidly absorbable sugar that can quickly raise the child's blood glucose levels, alleviating the symptoms of hypoglycemia. The child's symptoms, including slurred speech and diaphoresis, are indicative of a need for immediate intervention to raise blood sugar levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Apply cold packs to the lower abdomen. This is the correct answer because applying cold packs to the lower abdomen can help alleviate dysmenorrhea (painful menstrual cramps). Cold therapy helps to constrict blood vessels, reducing blood flow to the area and thus reducing pain. It's a non-pharmacological approach to managing menstrual cramps.
Choice B rationale:
Increase daily intake of fat. Increasing fat intake is not a recommended approach for managing dysmenorrhea. Balanced nutrition is important, but increasing fat intake is unlikely to significantly impact menstrual cramps. Other strategies are more effective.
Choice C rationale:
Massage the lower back area. Massaging the lower back can help with muscle relaxation and may provide some relief, but it is not as effective as applying cold packs to the lower abdomen for dysmenorrhea. Cold packs specifically target blood flow reduction to the area of pain.
Choice D rationale:
Limit physical activity. While it's generally a good idea to avoid strenuous physical activity during periods of intense pain, limiting physical activity alone is not the most effective strategy for managing dysmenorrhea. Cold packs and other interventions are more likely to provide relief.
Correct Answer is A
Explanation
Choice A rationale:
Stabilizing the nasogastric tube by taping it to the infant's cheek is a crucial step in preventing accidental removal or displacement of the tube during feedings. Infants are known for their active movements, which could lead to unintentional removal of the tube. Taping the tube securely helps maintain its proper placement and ensures the delivery of nutrients.
Choice B rationale:
Positioning the infant in a supine (lying on the back) position during feedings is not recommended. This position could lead to an increased risk of aspiration, where the feedings could enter the airway and lungs, causing respiratory issues. The recommended position for nasogastric tube feedings is semi-upright or upright to minimize this risk.
Choice C rationale:
Aspirating residual fluid from the infant's stomach and discarding it is not standard practice for nasogastric tube feedings. Aspirating can introduce the risk of infection or cause irritation to the stomach lining. Additionally, residual fluid can provide valuable information about the infant's digestion and absorption, and its presence should be taken into consideration when adjusting feedings.
Choice D rationale:
Microwaving the infant's formula to a temperature of 41°C (105.8°F) is not safe. Formula should be warmed gently using warm water or a bottle warmer to avoid overheating, which could burn the infant's mouth and esophagus. Microwaving can cause uneven heating and lead to hot spots within the formula, posing a risk of burns.
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