A 14-year-old client with type 1 diabetes is participating in a school sports event. The nurse provides education to the client about managing blood glucose levels during physical activity. Which statement by the client indicates a need for further teaching?
- A. I should check my blood sugar before and after exercise
- B. I need to eat a snack before I start playing
- C. If my blood sugar is high, I should skip my insulin dose before exercise
- D. I should carry a fast-acting carbohydrate with me during sports
Correct Answer: C
Rationale: The correct answer is C. Skipping insulin dose when blood sugar is high before exercise can be harmful. It is essential to manage blood glucose levels carefully during physical activity, which may require adjustments to insulin doses but skipping doses is not recommended. It is crucial to maintain blood sugar levels within the target range to prevent complications during exercise.
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An infant with tetralogy of Fallot becomes acutely cyanotic and hyperpneic. Which action should the nurse implement first?
- A. Administer morphine sulfate.
- B. Start IV fluids.
- C. Place the infant in a knee-chest position.
- D. Provide 100% oxygen by face mask.
Correct Answer: C
Rationale: In a situation where an infant with tetralogy of Fallot is acutely cyanotic and hyperpneic, the priority action should be to place the infant in a knee-chest position. This position helps increase systemic vascular resistance, improving pulmonary blood flow and subsequently ameliorating the cyanosis and hyperpnea. It is a non-invasive and effective intervention that can be promptly implemented by the nurse to address the immediate respiratory distress.
During a well-baby exam, a nurse finds that a 2-month-old's right testicle is not descended into the scrotum, but the left one is palpable. What should the nurse do?
- A. Ask if the right testis has been seen in the scrotum before
- B. Address potential concerns about future fertility
- C. Schedule an ultrasound to confirm the position of the testicle
- D. Prepare to obtain a urine specimen for culture
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The parents of a 3-month-old infant are being educated by the healthcare provider about safe sleep practices. Which statement by the parents indicates a need for further teaching?
- A. We will place our baby on their back to sleep
- B. We will use a firm mattress and avoid soft bedding
- C. We will keep our baby in our bed so we can monitor them closely
- D. We will avoid putting toys or pillows in the crib
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is assessing a 4-year-old child who is brought to the clinic for a routine checkup. The child's parent reports that the child has been more irritable and less active over the past week. The nurse notes a petechial rash on the child's trunk and extremities. What should the nurse do first?
- A. Ask the parent about recent exposure to contagious diseases
- B. Review the child's immunization record
- C. Measure the child's temperature
- D. Notify the healthcare provider immediately
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 4-month-old girl is brought to the clinic by her mother because she has had a cold for 2 or 3 days and woke up this morning with a hacking cough and difficulty breathing. Which additional assessment finding should alert the nurse that the child is in acute respiratory distress?
- A. Bilateral bronchial breath sounds.
- B. Diaphragmatic respiration.
- C. A resting respiratory rate of 35 breaths per minute.
- D. Flaring of the nares.
Correct Answer: D
Rationale: Flaring of the nares is a classic sign of acute respiratory distress in infants. It indicates increased work of breathing and is a visible cue that the child is struggling to breathe. This finding should alert healthcare providers to the severity of the respiratory distress and the need for prompt intervention to support the child's breathing.