A nurse is collecting data from an adolescent who has diabetes mellitus and is receiving glucagon therapy. Which of the following findings indicates the therapy has been effective?
Increased alertness
Diaphoresis
Blood glucose 50 mg/dL
Urine ketones +3
The Correct Answer is C
Choice A reason:
Increased alertness may be a sign of improved glucose levels, but it is not as direct an indicator as a blood glucose measurement.
Choice B reason:
Diaphoresis is a symptom of low blood glucose levels and indicates the need for intervention rather than effectiveness of therapy.
Choice C reason:
A blood glucose level of 50 mg/dL is within the normal range and indicates that the glucagon therapy has been effective in raising blood glucose levels.
Choice D reason:
The presence of urine ketones indicates that the body is using fats for energy, which may occur in the absence of adequate glucose. This is not an indicator of the effectiveness of glucagon therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Taping the wire to the palm of the hand can be uncomfortable for the child and may interfere with blood flow.
Choice B reason:
Warming the skin prior to probe placement is not a standard practice for pulse oximetry monitoring.
Choice C reason:
Applying the sensor to the index fingernail is not a recommended site for pulse oximetry monitoring in children.
Choice D reason:
Repositioning the probe every 2 hours helps to prevent skin breakdown and ensures accurate readings over time. This is a standard practice in pulse oximetry monitoring.
Correct Answer is C
Explanation
Choice A reason:
Reducing fiber intake is not necessary for a client in skeletal traction. Maintaining a balanced diet, including fiber, is important for overall health.
Choice B reason:
The nurse should not lift the traction weights off the floor. The weights must hang freely to provide the necessary traction.
Choice C reason:
Performing passive range-of-motion exercises helps prevent stiffness and muscle atrophy in the affected extremity. This is an important nursing intervention for a client in skeletal traction.
Choice D reason:
Applying protective padding to the pin sites is essential to prevent pressure and irritation. However, this action alone does not address the need for range-of-motion exercises.
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