A nurse is caring for an 11-year-old child who has type 1 diabetes mellitus and receives insulin injections. The child is experiencing an altered mental status, diaphoresis, and tremors. Which of the following actions should the nurse take?
Give the child 3 to 6 oz of orange juice.
Give the child a candy bar.
Administer glucagon to the vastus lateralis.
Administer DSW intravenous fluids.
The Correct Answer is A
A. Give the child 3 to 6 oz of orange juice. The child's altered mental status, diaphoresis, and tremors indicate hypoglycemia. The best initial treatment for mild to moderate hypoglycemia is a fast-acting carbohydrate, such as orange juice (3 to 6 oz) to rapidly raise blood glucose levels.
B. Give the child a candy bar. While candy contains sugar, it also contains fat, which slows glucose absorption, delaying the correction of hypoglycemia.
C. Administer glucagon to the vastus lateralis. Glucagon is used for severe hypoglycemia (e.g., unconsciousness or seizures), not for mild to moderate symptoms.
D. Administer D5W intravenous fluids. IV dextrose is used in severe cases where the child is unconscious or unable to take oral glucose. Since this child is conscious, oral treatment is preferred.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Avoid massaging the skin under the straps." Gentle massage is recommended to promote circulation and prevent skin breakdown.
B. "Use lotion on the skin under the harness." Lotion or powders should be avoided because they can cause skin irritation and breakdown.
C. "Adjust the harness straps weekly." Only the healthcare provider should adjust the straps to ensure proper hip positioning.
D. "Place the diaper under the straps." This helps keep the harness clean and dry, preventing skin irritation and breakdown.
Correct Answer is B
Explanation
A. "The obstruction will be treated with a medication called indomethacin." Indomethacin is used to close a patent ductus arteriosus (PDA), not to treat coarctation of the aorta. Instead, prostaglandins may be used temporarily to keep the ductus arteriosus open and improve blood flow until surgery.
B. "Surgical repair is the recommended treatment for infants younger than 6 months old." Coarctation of the aorta does not resolve on its own and requires surgical intervention, typically within the first few months of life. Options include resection with end-to-end anastomosis or balloon angioplasty in some cases.
C. "The cardiologist will monitor your infant closely until they are able to receive treatment with a heart transplant." Heart transplant is not the standard treatment for coarctation of the aorta; surgery or catheter-based intervention is the preferred approach.
D. "Most cases resolve spontaneously without treatment by 12 months of age." Coarctation of the aorta does not resolve on its own. If left untreated, it can lead to heart failure, hypertension, and other complications.
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