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 C

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."Nausea and vomiting are more commonly associated with hyperglycemia, especially in diabetic ketoacidosis (DKA). They are not typical signs of hypoglycemia.

D. "The onset of low blood glucose usually occurs rapidly."Hypoglycemia often has a rapid onset, especially with missed meals or increased activity.

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Correct Answer is A

Explanation

A. Flush the tube with water:
This is the correct action to take first. Flushing the tube with water ensures that the tube is clear and functional before administering the bolus enteral feeding.

B. Measure stomach contents:
This is not the first action to take. Before measuring stomach contents, it's important to confirm that the tube is patent and clear by flushing it with water.

C. Elevate the head of the bed:
While elevating the head of the bed is important during and after enteral feedings to reduce the risk of aspiration, it is not the first step. The initial focus should be on verifying the tube's patency.

D. Return gastric content into the gastrostomy tube:
If there is resistance or difficulty flushing the tube, returning gastric contents into the tube may be necessary, but it's not the first action. The first step is to attempt to clear the tube with water.

A. Assist the client to low Fowler's position. B. Warm the feeding solution to body temperature. C. Discard any residual gastric contents. D. Test the pH of gastric aspirate.

Correct Answer is D

Explanation

A. Assist the client to low Fowler's position:
Placing the client in a semi-upright or low Fowler's position during and after the feeding helps prevent aspiration and facilitates digestion. This position reduces the risk of regurgitation and reflux.

B. Warm the feeding solution to body temperature:
Ensuring the feeding solution is at room temperature or slightly warmer can enhance the client's comfort and reduce the risk of cramping or discomfort caused by cold fluids.

C. Discard any residual gastric contents:
Before initiating a new feeding, it's essential to check and discard any residual gastric contents from the previous feeding to prevent contamination, ensure accurate measurement, and minimize the risk of bacterial growth.

D. Test the pH of gastric aspirate:
Checking the pH of gastric aspirate is an important step to confirm the proper placement of the NG tube in the stomach. Gastric pH is typically acidic (pH less than 5), indicating the correct placement of the tube in the stomach rather than the respiratory tract, where the pH is higher (more alkaline).

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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 nurse is preparing to administer a bolus enteral feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take first?

Correct Answer is A

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?

Correct Answer is D

Explanation

A nurse is contributing to the plan of care for a client prescribed continuous enteral feedings. Which of the following actions should the nurse plan to take?

A nurse is collecting data on a client who is experiencing hypovolemia. Which of the following findings should the nurse expect?

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