A 10-year-old child with type 1 diabetes is admitted to the hospital with elevated blood glucose levels.
The pediatric nurse is preparing to administer insulin.
What is the most important step the nurse should take before administering insulin to ensure the safety of the child?
Ask the child if they have eaten recently.
Verify the child's identity and check the medication order.
Ensure the child is comfortable and relaxed.
Prepare the insulin in a syringe without checking the expiration date.
The Correct Answer is B
Choice A rationale
Asking if the child has eaten recently is important for understanding potential causes of elevated blood glucose and to consider the timing of insulin administration relative to meals. However, it does not directly ensure the medication being administered is correct for the right patient.
Choice B rationale
Verifying the child's identity using at least two identifiers and comparing the medication order to the prescription ensures that the right medication, dose, route, and time are being administered to the correct patient. This is a critical step in preventing medication errors and ensuring patient safety, especially with a high-risk medication like insulin.
Choice C rationale
Ensuring the child is comfortable and relaxed is beneficial for the child's overall well-being and can indirectly influence physiological parameters. However, it does not directly address the critical step of verifying the medication and patient identity before administration.
Choice D rationale
Preparing insulin without checking the expiration date is a medication error. Expired medications may have reduced potency or altered chemical properties, potentially leading to ineffective treatment or adverse effects. Checking the expiration date is a fundamental safety check.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Assessing for edema is an important nursing intervention in nephrotic syndrome because fluid retention due to decreased oncotic pressure is a common manifestation. However, preventing and monitoring for infection is a higher priority due to the immunosuppressed state of these children.
Choice B rationale
Providing a high-calorie diet is important to meet the increased metabolic needs associated with nephrotic syndrome and to compensate for energy loss. However, preventing infection takes precedence in nursing care.
Choice C rationale
Monitoring for signs of infection is the most important nursing intervention in a child with nephrotic syndrome. These children are at increased risk of infection due to protein loss (including immunoglobulins), edema compromising skin integrity, and potential immunosuppressive medications. Early detection and management of infection are critical to prevent serious complications. Normal temperature range is 97°F to 100.4°F (36.1°C to 38°C).
Choice D rationale
Encouraging high-protein snacks was a traditional recommendation but is now understood to potentially worsen proteinuria and is not the most important intervention. A moderate protein intake is generally recommended for children with nephrotic syndrome.
Correct Answer is B
Explanation
Choice A rationale
Instructing the student to avoid all physical activity is not the priority intervention. While reducing friction and sweating can be beneficial, completely ceasing activity may not be necessary with appropriate treatment and hygiene measures. The rash is likely a fungal infection, not exacerbated by moderate activity if properly managed.
Choice B rationale
Advising the student to apply an over-the-counter topical antifungal cream is the most appropriate initial intervention. The presentation of a well-demarcated, erythematous, scaly rash in the groin, sparing the scrotum and penis, in a wrestler wearing tight athletic gear strongly suggests tinea cruris, a fungal infection. Topical antifungals are the first-line treatment for this condition.
Choice C rationale
Referring the student for oral antibiotic therapy is not indicated at this stage. The clinical presentation is highly suggestive of a fungal infection, for which antibiotics are ineffective. Antibiotics are used to treat bacterial infections, which typically present with different characteristics such as pus or systemic symptoms.
Choice D rationale
Recommending a topical corticosteroid is not the priority. While corticosteroids can reduce inflammation and itching, they do not treat the underlying fungal infection and can sometimes worsen it by suppressing the local immune response. Antifungal treatment should be initiated first to address the cause of the rash.
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