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 C
Explanation
Infants with congenital heart defects may have difficulty with feeding due to increased effort required to breathe and feed at the same time. This can lead to poor weight gain and dehydration. Thus, it is important for the nurse to report any signs of poor feeding or oral intake to the healthcare provider. While audible heart murmur (choice A)and a high heart rate (choice B)are expected findings in infants with congenital heart defects, they do not necessarily indicate a need for immediate intervention. Weight gain of 2.2 lbs. (1 kg) in the last 48 hours (choice D)may actually be a positive finding in an infant with a congenital heart defect, but it is not as important to report as poor oral intake and suckling effort.

Correct Answer is A
Explanation
The child with gastroesophageal reflux should avoid acidic and spicy foods, as well as high-fat and high- sugar foods. Sugar cookies are a low-fat and low-sugar snack, which indicates that the child understands the dietary restrictions. Choices B, C, and D are high in fat, sugar, or acid and may exacerbate gastroesophageal reflux symptoms.

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