A nurse is reinforcing teaching about manifestations of hypoglycemia with an adolescent who has type 1 diabetes mellitus. Which of the following manifestations should the nurse include in the teaching?

Diminished reflexes

Rapid respirations

Acetone breath

Headache

Answer and Explanation

The Correct Answer is D

A. Diminished reflexes:
Explanation: Diminished reflexes are not typically associated with hypoglycemia. Instead, hypoglycemia may cause hyperactive reflexes or tremors.

B. Rapid respirations:
Explanation: Rapid respirations are not a common manifestation of hypoglycemia. In hypoglycemia, the body might respond with shallow, rapid breathing or hyperventilation.

C. Acetone breath:
Explanation: Acetone breath, often described as fruity or sweet, is associated with diabetic ketoacidosis (DKA), which is a complication of hyperglycemia rather than hypoglycemia.

D. Headache:
Explanation: Headache is a common manifestation of hypoglycemia. It can occur as a result of decreased glucose levels affecting the brain.

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Correct Answer is A

Explanation

A. Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen.
This is a correct action. Cleaning the wound with a sterile solution, such as 0.9% sodium chloride, helps minimize contamination and ensures a more accurate culture.

B. Irrigate the wound with an antiseptic prior to obtaining the specimen.
Using antiseptics directly on the wound before obtaining a specimen can interfere with the culture results. It's essential to use a non-bacteriostatic solution for cleaning.

C. Include intact skin at the wound edges in the culture.
The culture should focus on the material within the wound itself rather than including intact skin. The goal is to identify the specific pathogens causing the infection.

D. Swab an area of skin away from the wound to identify normal flora.
The specimen should be taken directly from the wound site to identify the pathogens responsible for the infection. Swabbing away from the wound won't provide relevant information.

A. 8.0 B. 6.0 C. 7.0 D. 4.0

Correct Answer is D

Explanation

A. 8.0: An aspirate pH of 8.0 would indicate an alkaline substance. This would not be typical of stomach contents, which are acidic. An alkaline pH might suggest placement in the intestines or respiratory tract.

B. 6.0: While this is less alkaline than 8.0, it is still not within the typical range for stomach contents. Stomach aspirate is generally more acidic.

C. 7.0: A pH of 7.0 is neutral. Stomach contents are typically more acidic, so a neutral pH would not be consistent with correct NG tube placement in the stomach.

D. 4.0: This is within the acidic range and is consistent with the pH of stomach contents. It would be considered an indication of correct NG tube placement in the stomach.

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A nurse is reinforcing teaching about manifestations of hypoglycemia with an adolescent who has type 1 diabetes mellitus. Which of the following manifestations should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound drainage specimen for culture?

Correct Answer is A

Explanation

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?

Correct Answer is D

Explanation

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