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 A
Explanation
Choice A rationale
Cryptorchidism is the medical term for the failure of one or both testicles to descend into the scrotum. The scenario describes a 2-year-old male with one non-palpable testicle, which is the hallmark of cryptorchidism. Risk factors include prematurity and low birth weight.
Choice B rationale
An inguinal hernia is a protrusion of abdominal contents through the inguinal canal. While it can present as a swelling in the groin area, it is distinct from a missing testicle in the scrotum. Examination would typically reveal a palpable mass that may reduce with gentle pressure.
Choice C rationale
A hydrocele is a collection of fluid within the tunica vaginalis, the sac surrounding the testicle. It typically presents as a painless swelling of the scrotum. The testicle is usually palpable within the fluid-filled sac.
Choice D rationale
Testicular torsion is a medical emergency involving the twisting of the spermatic cord, which cuts off blood supply to the testicle. It presents with sudden, severe scrotal pain, swelling, and often nausea and vomiting. The examination would reveal a tender, firm, and retracted testicle. .
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.
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