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 C

Explanation

When advising a new mother on caring for a child with croup, the telephone triage nurse should prioritize concern for difficulty swallowing secretions. This symptom can indicate that the child's airway is becoming obstructed and requires immediate medical attention. A fever of 101.0°F (38.3°C) is a common symptom of croup and can be managed at home with antipyretics. Crying often when nursing is not a specific symptom of croup and may have other causes. A barking cough, worse at night, is a characteristic symptom of croup and can be managed at home with humidified air and hydration.

A. Apply lotion to hands and feet. B. Encourage the child to rest when possible. C. Place the child in a quiet environment. D. Make a list of foods that the child likes.

Correct Answer is C

Explanation

The nurse should instruct the mother to place the child in a quiet environment first. Kawasaki disease is an illness that can cause inﬂammation in the blood vessels and can lead to symptoms such as irritability and skin peeling. Placing the child in a quiet environment can help reduce stimulation and promote rest, which can help improve the child's symptoms. The other options (A, B, and D) may also be helpful, but placing the child in a quiet environment is a key intervention in this situation.

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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

When advising a new mother on caring for a child with croup, which symptom should be a priority concern for the telephone triage nurse?

Correct Answer is C

Explanation

A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both hands and feet. Which intervention should the nurse instruct the mother to implement first?

Correct Answer is C

Explanation

The nurse is assessing a preschool-aged child who presents with ﬂank pain, dysuria, and low-grade fever. To determine a possible urinary tract infection, which additional information should the nurse gather from the parent?

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