The nurse is caring for an adolescent with type 1 diabetes mellitus presenting with an HbA1c of 11% (97 mmol/mol), thirst, and blurred vision. Which action should the nurse take first?
Review prior insulin prescriptions.
Obtain point-of-care glucose.
Assess urine for ketones.
Check blood pressure.
The Correct Answer is B
The adolescent's symptoms suggest that their blood glucose levels may be very high. Obtaining a point-of- care glucose reading is the first step in assessing the adolescent's current blood glucose levels and determining the appropriate course of action.
Reviewing prior insulin prescriptions, assessing urine for ketones, and checking blood pressure are also important interventions but should occur after the blood glucose level has been determined.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Children with autism spectrum disorder may have difficulty with sensory processing, social interactions, and communication, which can contribute to feeding difficulties and failure to thrive. Providing structured meal times is an important intervention to help establish a routine and promote consistency and predictability.
Structured meal times involve setting a specific time for meals and snacks, providing a calm and quiet environment, and limiting distractions. This can help the child focus on the task of eating and reduce sensory overload that may interfere with feeding. The nurse should also ensure that the child is seated comfortably and at an appropriate height for feeding.
Offering food even if disinterested (B), incorporating play during meals (C), and allowing multiple food choices (D) are not necessarily helpful interventions for a toddler with autism spectrum disorder and failure to thrive. Offering food when the child is not interested may reinforce negative feeding behaviors and can contribute to further feeding difficulties. Incorporating play during meals may distract the child from the task of eating and can be counterproductive. Allowing multiple food choices can be overwhelming for the child and may not promote a consistent and structured feeding routine.
Therefore, the nurse should prioritize providing structured meal times as an important intervention for promoting feeding and growth in a toddler with autism spectrum disorder and failure to thrive.
Correct Answer is B
Explanation
When caring for a child in balanced suspension skeletal traction, the most important intervention for the nurse to implement is monitoring peripheral pulses and sensation in the affected leg to detect any compromise in circulation or nerve function. This is crucial because the traction places tension on the bones, which can result in nerve or vascular damage.
Changing positions every 2 hours is important to prevent pressure injuries, but it is not the most critical intervention.
Cleansing pin sites and assessing skin for redness and signs of tissue breakdown are also important, but they are not as urgent as monitoring peripheral pulses and sensation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today