The nurse is caring for an adolescent with type 1 diabetes mellitus who presents with an HbA1c of 11% (97 mmol/mol), thirst, and blurred vision.

What action should the nurse take first?

Obtain point-of-care glucose.

Assess urine for ketones.

Check blood pressure.

Review prior insulin prescriptions.

Answer and Explanation

The Correct Answer is A

Choice A rationale
The first action the nurse should take when caring for an adolescent with type 1 diabetes mellitus who presents with an HbA1c of 11% (97 mmol/mol), thirst, and blurred vision is to obtain point-of-care glucose. These symptoms are indicative of hyperglycemia, and immediate blood glucose testing is necessary to confirm this and guide further treatment.
Choice B rationale
Assessing urine for ketones is important in managing diabetes, especially in cases of suspected diabetic ketoacidosis. However, this would not be the first action to take in this scenario.
Choice C rationale
Checking blood pressure is a standard part of any physical assessment, but it would not be the first action to take in this scenario.
Choice D rationale
Reviewing prior insulin prescriptions can provide valuable information about the patient’s management of their diabetes, but it would not be the first action to take in this scenario.

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Correct Answer is ["1.3"]

Explanation

Step 1: First, convert the child’s weight from pounds to kilograms. Since 1 pound is approximately 0.45 kilograms, an 18-pound child weighs about 8.16 kilograms (18 pounds × 0.45 kg/pound).

Step 2: Next, calculate the total daily dosage of amoxicillin. The prescribed dosage is 25 mg/kg/day. Therefore, the total daily dosage is 204 mg/day (8.16 kg × 25 mg/kg).

Step 3: Since the medication is to be administered in two divided doses every 12 hours, each dose should be half of the total daily dosage. Therefore, each dose is 102 mg (204 mg/day ÷ 2).

Step 4: Finally, calculate the volume of the suspension to be administered for each dose. The label on the bottle reads, “Amoxicillin for Oral Suspension, USP 400 mg per 5 mL.”. Therefore, each milliliter of the suspension contains 80 mg of amoxicillin (400 mg/5 mL). To administer a dose of 102 mg, the nurse should administer approximately 1.275 mL (102 mg ÷ 80 mg/mL). If rounding is required, round to the nearest tenth.

Therefore, the nurse should administer 1.3 mL for each dose.

A. Check for signs of teeth clenching or grinding B. Inspect the back of the throat C. Stimulate the gag reflex by touching the tonsillar pillars D. Ask the child to speak to assess for any changes in voice tone .

Correct Answer is B

Explanation

Choice A rationale
Checking for signs of teeth clenching or grinding is not typically necessary in a child who has undergone a tonsillectomy and is swallowing frequently. These signs are not typically associated with post-tonsillectomy complications.
Choice B rationale
Inspecting the back of the throat is an appropriate action for the nurse to take next. Frequent swallowing can be a sign of bleeding in the throat, which is a potential complication of tonsillectomy. By inspecting the back of the throat, the nurse can assess for signs of bleeding.
Choice C rationale
Stimulating the gag reflex by touching the tonsillar pillars is not typically necessary in a child who has undergone a tonsillectomy and is swallowing frequently. This action could potentially cause discomfort or induce vomiting.
Choice D rationale
Asking the child to speak to assess for any changes in voice tone is not typically necessary in a child who has undergone a tonsillectomy and is swallowing frequently. Changes in voice tone are not typically associated with post-tonsillectomy complications.

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The nurse is caring for an adolescent with type 1 diabetes mellitus who presents with an HbA1c of 11% (97 mmol/mol), thirst, and blurred vision. What action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["1.3"]

Explanation

While checking the vital signs of a 10-year-old child who underwent a tonsillectomy earlier in the day, the nurse notices the child swallowing every 2 to 3 minutes. What action should the nurse take next?

Correct Answer is B

Explanation

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The nurse is caring for an adolescent with type 1 diabetes mellitus who presents with an HbA1c of 11% (97 mmol/mol), thirst, and blurred vision.

What action should the nurse take first?