A nurse is caring for a preschooler who has diabetes mellitus and is pale, diaphoretic, and irritable. The child's blood glucose level is 52 mg/dL. Which of the following actions should the nurse take first?
Give 1 tsp of peanut butter to the child.
Recheck the child's blood glucose level.
Administer 1 tbsp of sugar to the child.
Document the incident in the child's record.
The Correct Answer is C
Rationale:
A) Peanut butter is not a rapidly absorbed source of glucose and may not be appropriate for treating hypoglycemia.
B) While rechecking the child's blood glucose level is important, immediate treatment should be initiated for symptomatic hypoglycemia.
C) Administering a rapidly absorbed source of sugar, such as 1 tablespoon of sugar or honey, is the priority intervention for treating hypoglycemia in a conscious child.
D) Documenting the incident is important but should not delay the administration of treatment for hypoglycemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A) Using an automated lancet device provides a controlled and consistent depth of puncture for the heel stick, minimizing discomfort and risk of injury.
B) Applying limb restraints is unnecessary and could cause distress to the infant.
C) Puncturing the heel at the inner aspect may not be the appropriate site for the heel stick.
D) Cleansing the area with povidone iodine is not necessary for a routine heel stick procedure.
Correct Answer is C
Explanation
Rationale:
A) Inability to hold a bottle is typically achieved by 4-6 months, so it might indicate a developmental delay.
B) Palmar grasp is a primitive reflex typically seen in newborns, and it should be replaced by more voluntary grasping patterns by 8 months.
C) Sitting unsupported is a milestone typically achieved by 6-8 months, indicating expected growth and development at 8 months.
D) Forcing the tongue outward when touched might indicate tongue thrust reflex, which should typically disappear around 4-6 months.
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