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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
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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