A nurse is collecting data from an adolescent who has diabetes mellitus and is receiving glucagon therapy. Which of the following findings indicates the therapy has been effective?
Increased alertness
Diaphoresis
Blood glucose 50 mg/dL
Urine ketones +3
The Correct Answer is C
Choice A reason:
Increased alertness may be a sign of improved glucose levels, but it is not as direct an indicator as a blood glucose measurement.
Choice B reason:
Diaphoresis is a symptom of low blood glucose levels and indicates the need for intervention rather than effectiveness of therapy.
Choice C reason:
A blood glucose level of 50 mg/dL is within the normal range and indicates that the glucagon therapy has been effective in raising blood glucose levels.
Choice D reason:
The presence of urine ketones indicates that the body is using fats for energy, which may occur in the absence of adequate glucose. This is not an indicator of the effectiveness of glucagon therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Administering digoxin should be based on the infant's specific heart rate and the healthcare provider's prescription, rather than a specific pulse value.
Choice B reason:
Allowing for frequent rest periods is important for an infant with heart failure, as it helps conserve energy and reduce cardiac workload.
Choice C reason:
Feeding duration should be based on the infant's tolerance and ability to feed effectively, rather than a specific time frame.
Choice D reason:
Maintaining the infant in a supine position can help with respiratory function but should be balanced with appropriate positioning to prevent aspiration and promote comfort. It is not the sole action to include in the plan of care.
Correct Answer is D
Explanation
Choice A reason:
The color tool is not a pain assessment tool; it is used to assess oxygen saturation levels.
Choice B reason:
The FACES scale is commonly used for children who are 3 years of age and older, but it may not be suitable for an 18-month-old toddler who may have limited ability to express pain through facial expressions.
Choice C reason:
The visual analog scale is typically used for older children and adults. It may not be effective for assessing pain in an 18-month-old toddler.
Choice D reason:
The FLACC scale (Face, Legs, Activity, Cry, Consolability) is a validated pain assessment tool for young children, including toddlers. It evaluates specific behaviors related to pain, making it suitable for this age group.
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