A nurse is reinforcing discharge teaching with the parent of a child who has a new diagnosis of diabetes mellitus. Which of the following statements by the parent requires a clarification of the teaching?

"Sweating can occur with hypoglycemia."

"My son might complain of feeling shaky when he has a low blood glucose level."

"My son might have nausea and vomiting with hypoglycemia."

"The onset of low blood glucose usually occurs rapidly."

Answer and Explanation

The Correct Answer is D

A. "Sweating can occur with hypoglycemia."
Explanation: This statement is correct. Sweating is one of the common symptoms of hypoglycemia. When blood glucose levels drop too low, the body releases stress hormones, including adrenaline, which can lead to sweating.

B. "My son might complain of feeling shaky when he has a low blood glucose level."
Explanation: This statement is correct. Shaking or feeling shaky is a common symptom of hypoglycemia. It results from the release of stress hormones in response to low blood glucose.

C. "My son might have nausea and vomiting with hypoglycemia."
Explanation: This statement is correct. Nausea and vomiting can be symptoms of hypoglycemia. While not everyone with low blood glucose will experience these symptoms, they are possible manifestations.

D. "The onset of low blood glucose usually occurs rapidly."
Explanation: This statement is generally true, but it can vary. The onset of hypoglycemia can happen rapidly, especially if the individual has taken a fast-acting insulin or medication. However, the speed of onset can depend on various factors, and it's important to emphasize that it may not always be immediate.

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Correct Answer is B

Explanation

A. The nurse administers the feeding through a syringe barrel by gravity.
This is an appropriate method for administering intermittent tube feedings. Gravity feeding with a syringe allows for controlled delivery of the feeding solution.

B. The nurse allows the client to rest in a supine position during feeding.
Feeding a client in a supine position is generally acceptable, especially if the client is comfortable and doesn't experience complications. However, if there are specific contraindications or concerns for aspiration, the nurse should follow the prescribed position guidelines.

C. The nurse irrigates the NG tube with tap water after feeding.
Using tap water to irrigate an NG tube is not recommended, as it may lead to complications such as electrolyte imbalances. Sterile or distilled water should be used for irrigation.

D. The nurse initiates the feeding after aspirating 50 mL of gastric residual.
This is an appropriate action. Aspirating gastric residual before initiating a feeding helps assess the presence of gastric contents, ensuring that the client is ready to receive the feeding. However, specific institutional policies may dictate the threshold for gastric residual volume that requires intervention.

A. Abrasion B. Contusion C. Laceration D. Puncture

Correct Answer is C

Explanation

A. Abrasion:
This type of wound occurs when the skin rubs or scrapes against a rough surface. It's often referred to as a "scrape" and typically involves superficial damage to the skin without penetration or tearing.

B. Contusion:
Commonly known as a bruise, a contusion results from blunt trauma to the body, causing blood vessels to break and leak blood into the surrounding tissues. The skin remains intact, but there's discoloration due to the blood.

C. Laceration:
This type of wound involves a tear or irregular cut in the skin, often with jagged or rough edges. Lacerations typically result from sharp or blunt trauma that causes the skin to tear.

D. Puncture:
Puncture wounds occur when a sharp object pierces the skin and underlying tissues, creating a small, deep hole. These wounds might not bleed much externally but can cause damage to internal structures and carry a risk of infection due to the depth and possible trapping of debris.

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A nurse is reinforcing discharge teaching with the parent of a child who has a new diagnosis of diabetes mellitus. Which of the following statements by the parent requires a clarification of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene?

Correct Answer is B

Explanation

A nurse is assisting with the care of a client who arrives at the emergency department after an industrial explosion. The nurse inspects the wound on the client's leg has and finds torn skin tissue underneath. The nurse should report this as which of the following types of wounds?

Correct Answer is C

Explanation

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the tube feeding?

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

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A nurse is assisting with teaching a client about water-soluble vitamins. Which of the following vitamins should the nurse include?

A nurse is caring for a client who requires an NG tube. After inserting the tube, the nurse tests the pH of the client's aspirate. Which of the following pH levels should the nurse identify as an indication of correct placement of the tube?

A nurse is caring for a client who has gestational diabetes and reports feeling shaky, sweaty, and having blurred vision. The client's blood glucose level is 48 mg/dL. Which of the following foods should the nurse give to the client? (Select all that apply).

A nurse is assisting with teaching a client who is on a soft diet. Which of the following foods should the nurse include in the teaching?

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the client's skin integrity?