The nurse is caring for an adolescent with type 1 diabetes mellitus who presents with an HbA1c of 11% (97 mmol/mol), thirst, and blurred vision.
What action should the nurse take first?
Obtain point-of-care glucose.
Assess urine for ketones.
Check blood pressure.
Review prior insulin prescriptions.
The Correct Answer is A
Choice A rationale
The first action the nurse should take when caring for an adolescent with type 1 diabetes mellitus who presents with an HbA1c of 11% (97 mmol/mol), thirst, and blurred vision is to obtain point-of-care glucose. These symptoms are indicative of hyperglycemia, and immediate blood glucose testing is necessary to confirm this and guide further treatment.
Choice B rationale
Assessing urine for ketones is important in managing diabetes, especially in cases of suspected diabetic ketoacidosis. However, this would not be the first action to take in this scenario.
Choice C rationale
Checking blood pressure is a standard part of any physical assessment, but it would not be the first action to take in this scenario.
Choice D rationale
Reviewing prior insulin prescriptions can provide valuable information about the patient’s management of their diabetes, but it would not be the first action to take in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1"]
Explanation
Step 1 is: Identify the prescribed dose, which is 5 mg.
Step 2 is: Identify the concentration of the medication, which is 5 mg per 5 mL.
Step 3 is: Calculate the volume to administer using the formula: (Prescribed dose ÷ Concentration) × Volume. So, (5 mg ÷ 5 mg/5 mL) = 5 mL. Since 1 teaspoon is approximately 5 mL, the nurse should instruct the parent to give 1 teaspoon with each dose.
Correct Answer is B
Explanation
Choice A rationale
Checking for signs of teeth clenching or grinding is not typically necessary in a child who has undergone a tonsillectomy and is swallowing frequently. These signs are not typically associated with post-tonsillectomy complications.
Choice B rationale
Inspecting the back of the throat is an appropriate action for the nurse to take next. Frequent swallowing can be a sign of bleeding in the throat, which is a potential complication of tonsillectomy. By inspecting the back of the throat, the nurse can assess for signs of bleeding.
Choice C rationale
Stimulating the gag reflex by touching the tonsillar pillars is not typically necessary in a child who has undergone a tonsillectomy and is swallowing frequently. This action could potentially cause discomfort or induce vomiting.
Choice D rationale
Asking the child to speak to assess for any changes in voice tone is not typically necessary in a child who has undergone a tonsillectomy and is swallowing frequently. Changes in voice tone are not typically associated with post-tonsillectomy complications.
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