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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

For an eight-month-old infant with heart failure, the nurse should withhold digoxin if the infant's apical pulse is less than 90 beats/minute and notify the healthcare provider. In this case, the infant's apical pulse is 88 beats/minute, so the nurse should withhold the digoxin and notify the healthcare provider.

Furosemide ( B), hydralazine (C), and enalapril (D) do not have specific parameters for withholding based on the infant's vital signs.

A. Hemiplegia. B. Fever. C. Vigorous feeding and satiation. D. Hypotension and tachycardia.

Correct Answer is D

Explanation

Aortic stenosis is a narrowing of the aortic valve, which can cause decreased blood ﬂow from the left ventricle to the systemic circulation. In infants with aortic stenosis, the left ventricle must work harder to pump blood through the narrowed valve, which can lead to left ventricular hypertrophy, heart failure, and pulmonary edema. Bilateral fine crackles in both lung fields may indicate ﬂuid overload in the lungs, which is a common complication of heart failure. Hypotension and tachycardia may also be present due to decreased cardiac output.

Option A is not a typical finding associated with aortic stenosis.

Option B is not directly related to the infant's cardiac condition.

Option C is not a typical finding associated with heart failure.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is assessing an infant with aortic stenosis and identifies bilateral fine crackles in both lung fields. Which additional finding should the nurse expect to obtain?

Correct Answer is D

Explanation

During her sports physical examination, 15-year-old female requests oral contraceptives. She explains that she is sexually active and does not want her parents to know. Which action should the nurse take?

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