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:
The FLACC (Face, Legs, Activity, Cry, Consolability) scale is a pain assessment tool commonly used for infants and young children who cannot verbalize their pain. It assesses different behavioral and physiological indicators of pain, such as facial expressions, leg movement, activity level, crying, and response to consoling. Given that the infant is only 18 months old, this scale is appropriate for evaluating their postoperative pain.
Choice B rationale:
The Color tool is not a recognized pain assessment tool. It's essential to use validated and standardized pain assessment scales, and the Color tool does not fit this criterion.
Choice C rationale:
The Poker Chip Tool is not typically used for pain assessment in infants. It's often used with older children to assess pain intensity using a poker chip set that corresponds to different levels of pain. However, for an 18-month-old infant, behavioral assessments like the FLACC scale would be more suitable.
Choice D rationale:
The Numeric scale involves asking the patient to rate their pain on a numerical scale, often from 0 to 10. However, this scale is not appropriate for an 18-month-old infant who is likely unable to comprehend or use numbers to express their pain. The FLACC scale provides a more comprehensive assessment of pain in non-verbal or preverbal children.
Correct Answer is C
Explanation
Choice A rationale:
This medication can cause ringing in the ears (Choice A) is not a common side effect of amoxicillin. Ringing in the ears (tinnitus) is not typically associated with the use of this antibiotic.
Choice B rationale:
This medication can cause muscle pain (Choice B) is not a common side effect of amoxicillin. Muscle pain is not among the usual adverse reactions associated with its use.
Choice C rationale:
This medication can cause loose stools (Choice C) is a relevant side effect of amoxicillin. Antibiotics, including amoxicillin, can disrupt the normal balance of gut bacteria, potentially leading to gastrointestinal disturbances such as diarrhea or loose stools.
Choice D rationale:
This medication can cause blurred vision (Choice D) is not a common side effect of amoxicillin. Blurred vision is not a typical adverse effect associated with the use of this antibiotic.
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