The nurse is reviewing the history and physical notes, as well as the nurse’s notes and laboratory results for a child.
The child is developmentally appropriate, interacting with his parents, and is in the percentile for weight and height.
The child’s lung sounds are clear and equal, a murmur is noted upon auscultation, and clubbing of the fingers is observed.
There is no skin breakdown, and the mucous membranes are pink and moist.
What condition is the child most likely experiencing, what two actions should the nurse take for this condition, and what two parameters should the nurse monitor to assess the child’s progress?

Choice A rationale

Exercise is an important part of managing type 2 diabetes as it helps regulate blood glucose levels. When you exercise, your muscles use sugar (glucose) for energy. Regular physical activity also helps your body use insulin more efficiently. Therefore, the statement “Remember exercise will not affect blood glucose levels” is incorrect.

Choice B rationale

Moderate alcohol consumption is generally safe for most people with diabetes. A moderate amount of alcohol is up to one drink a day for women of all ages and men older than age 65, and up to two drinks a day for men age 65 and younger. Too much alcohol can cause blood sugar levels to drop too low and can also increase the risk of other health problems.

Choice C rationale

While it’s important to keep wounds clean and covered, using antibiotic ointment on every wound isn’t always necessary. Overuse of antibiotics can lead to antibiotic resistance. It’s best to consult with a healthcare provider for wound care advice.

Choice D rationale

Soaking feet in hot water can lead to burns or infections, especially if the person has neuropathy. It’s recommended to wash feet with warm — not hot — water and dry them gently, especially between the toes.

Choice A rationale

Responding to the code while performing tracheostomy care could potentially put the current patient at risk. The nurse has a responsibility to ensure the safety of the patient they are currently caring for.

Choice B rationale

Closing the room door does not address the immediate needs of either patient and does not contribute to the safety or care of the patients.

Choice C rationale

Calling for an assistant is the most appropriate action. This allows the nurse to ensure the safety of the current patient while also allowing for a response to the code blue. The assistant can continue care for the current patient, or the nurse can delegate the assistant to respond to the code while the nurse continues care for the current patient.

Choice D rationale

Finishing the procedure could delay response to the code blue, potentially putting the other patient at risk.