A nurse is reinforcing teaching with a school-age child who has type 1 diabetes mellitus and his parent about illness management. Which of the following instructions should the nurse include?
Withhold insulin dose if feeling nauseous.
Test the urine for ketones.
Limit fluid intake during meal time.
Notify the provider if blood glucose levels are over 350 mg/dL.
The Correct Answer is B
Choice A rationale
Withholding insulin when feeling nauseous is not recommended. Insulin is necessary for the body to use glucose for energy. Without insulin, glucose stays in the bloodstream, leading to high blood sugar levels.
Choice B rationale
Testing the urine for ketones is important in managing type 1 diabetes. When the body does not have enough insulin, it breaks down fat as fuel. This process produces a buildup of acids in the bloodstream called ketones, eventually leading to diabetic ketoacidosis if untreated.
Choice C rationale
Limiting fluid intake during mealtime is not specifically related to the management of type 1 diabetes. It’s important to stay hydrated, but it doesn’t directly affect blood glucose levels.
Choice D rationale
Notifying the provider if blood glucose levels are over 350 mg/dL is not the only time medical advice should be sought. Any persistent, unusual, or extreme blood glucose reading should be discussed with a healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Weighing the infant every day on the same scale at the same time is crucial in monitoring excess fluid volume in congestive heart failure. Sudden weight gain can indicate fluid retention, a common sign of worsening heart failure. Daily weight monitoring helps in early detection and timely intervention.
Choice B rationale:
Notifying the physician when weight gain exceeds more than 20 g/day might be too late for intervention. Daily weight monitoring is essential to detect trends and intervene promptly to manage excess fluid volume.
Choice C rationale:
Placing the infant in a car seat to minimize movement is not directly related to managing excess fluid volume in congestive heart failure. It is essential for safety during transportation but does not address the nursing diagnosis.
Choice D rationale:
Administering digoxin as ordered by the physician is a medical intervention for congestive heart failure. While important, the nursing diagnosis is related to excess fluid volume, and the focus should be on nursing interventions such as monitoring daily weights.
Correct Answer is ["1170 "]
Explanation
Step 1 is to convert all fluid intake to mL.
Using the conversion factor 1 oz = 30 mL7 and 1 cup
= 240 mL8, we get: 1 cup of coffee = 240 mL 4 oz of orange juice = 4 × 30 mL = 120 mL 3 oz of water = 3 × 30 mL = 90 mL 1 cup of flavored gelatin = 240 mL 1 cup of tea = 240 mL 5 oz of broth = 5 × 30 mL = 150 mL 3 oz of water = 3 × 30 mL = 90 mL Step 2 is to add up all the mL values: 240 mL (coffee) + 120 mL (orange juice) + 90 mL (water) + 240 mL (gelatin) + 240 mL(tea) + 150 mL (broth) + 90 mL (water) = 1170 mL So, the nurse should record a fluid intake of 1170 mL.
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