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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?
- A. Withhold insulin dose if feeling nauseous.
- B. Test the urine for ketones.
- C. Limit fluid intake during meal time.
- D. Notify the provider if blood glucose levels are over 350 mg/dL.
Correct Answer: B
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. 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. 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. 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.
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A nurse in an urgent care clinic is assisting with the care of a toddler who ingested 30 tablets of aspirin. Which of the following substances should the nurse administer to the toddler?
- A. Activated charcoal
- B. A chelating agent
- C. Acetylcysteine
- D. Digoxin immune FAB
Correct Answer: A
Rationale: Activated charcoal is often used in cases of drug overdose or poisoning, including aspirin ingestion. It works by binding to the drug or toxin in the stomach, preventing it from being absorbed into the body. This makes activated charcoal an effective treatment for aspirin overdose in a toddler. A chelating agent is a substance that can bind to heavy metals in the body, helping to remove them. While useful in cases of heavy metal poisoning, it would not be the first choice for an aspirin overdose. Acetylcysteine is an antidote for acetaminophen (Tylenol) overdose, not aspirin. It works by replenishing glutathione, a substance that helps to detoxify the liver. Digoxin immune FAB is used to treat digoxin toxicity. Digoxin is a medication used to treat heart conditions, and it is not related to aspirin.
A nurse is caring for a toddler whose parent states that the child has a mass in his abdominal area and his urine is a pink color. Which of the following actions is the nurse's priority?
- A. Schedule the child for an abdominal ultrasound.
- B. Instruct the parent to avoid pressing on the abdominal area.
- C. Determine if the child is having pain.
- D. Obtain a urine specimen for a urinalysis.
Correct Answer: B
Rationale: Schedule the child for an abdominal ultrasound. While an ultrasound may be necessary for further diagnosis, it is not the immediate priority. The child's symptoms suggest a possible Wilms' tumor, a type of kidney cancer that primarily affects children. An ultrasound can help confirm this diagnosis, but it should not be the first action. Instruct the parent to avoid pressing on the abdominal area. This is the correct answer. If the child has a Wilms' tumor, pressing on the abdominal area could potentially cause the cancer to spread. Therefore, it is crucial to avoid any unnecessary pressure on the abdomen until further medical evaluation can be performed. Determine if the child is having pain. While assessing for pain is an important part of nursing care, it is not the immediate priority in this situation. The child's symptoms need urgent medical attention, and assessing for pain will not provide the necessary information to guide immediate care. Obtain a urine specimen for a urinalysis. Although a urinalysis can provide valuable information about a patient's health, it is not the immediate priority in this situation. The child's symptoms suggest a possible Wilms' tumor, which requires immediate medical attention. A urinalysis may be part of the diagnostic process, but it should not be the first action taken.
A nurse is preparing to administer acetaminophen 10mg/kg PO to a preschool child for fever. The child weighs 22 lb. Available is acetaminophen liquid 160 mg/5 mL. How many mL should the nurse administer?
- A. 3.125 mL
Correct Answer: A
Rationale: The child weighs 22 lb, which is approximately 10 kg (since 1 kg is approximately 2.2 lb). The prescribed dose of acetaminophen is 10 mg/kg. Step 1 is: Calculate the total dose of acetaminophen for the child. This is done by multiplying the child's weight in kg by the prescribed dose in mg/kg. 10 kg×10 mg/kg=100 mg The available acetaminophen liquid is 160 mg/5 mL. Step 2 is: Calculate the volume of acetaminophen liquid to administer. This is done by setting up a proportion with the total dose of acetaminophen and the concentration of the available liquid. x mL100 mg=5 mL160 mg Solving for x gives: x=160 mg mg×5 mL=3.125 mL Therefore, the nurse should administer approximately 3.125 mL of the acetaminophen liquid.
A nurse is assisting with the admission of a 2-year-old toddler who has acute gastroenteritis. Which of the following actions should the nurse take first?
- A. Initiate isotonic fluids with 20 mEq/L potassium chloride.
- B. Collect a stool sample from the toddler.
- C. Determine if the toddler is voiding.
- D. Request evaluation of the toddler's serum electrolytes.
Correct Answer: C
Rationale: Initiate isotonic fluids with 20 mEq/L potassium chloride. While it is important to maintain hydration in a child with acute gastroenteritis, initiating isotonic fluids with 20 mEq/L potassium chloride is not the first action a nurse should take. The child's hydration status and electrolyte balance need to be assessed first. The American Academy of Pediatrics recommends the use of isotonic solutions with adequate potassium chloride and dextrose for maintenance IV fluids in children. Collect a stool sample from the toddler Collecting a stool sample can help identify the cause of the gastroenteritis. However, this is not the first step. The stool sample collection should be done using a clean, dry toilet hat or plastic wrap. But before this, the child's hydration status needs to be assessed. Determine if the toddler is voiding The first action the nurse should take when using the nursing process is assessment. Therefore, checking if the toddler is voiding is the priority. This will help assess the child's hydration status, which is critical in managing acute gastroenteritis. Request evaluation of the toddler's serum electrolytes Requesting an evaluation of the toddler's serum electrolytes is also important, but it's typically done after the initial assessment. Fluid and electrolyte derangement are the immediate causes that increase the mortality in diarrhea. However, before requesting this evaluation, the nurse should first determine if the toddler is voiding to assess the child's hydration status.
A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the nurse's priority?
- A. Maintain a saline-lock.
- B. Place the child on a no-salt-added diet.
- C. Check the child's weight daily.
- D. Educate the parents about potential complications.
Correct Answer: C
Rationale: While maintaining a saline-lock can be important for administering medications or fluids, it is not the priority action. The nurse's priority should be to assess the child's condition and intervene to prevent complications. A no-salt-added diet may be recommended for some children with acute glomerulonephritis to help manage fluid balance and blood pressure. However, this is not the priority action. The nurse's priority should be to assess the child's condition and intervene to prevent complications. This is the correct answer. Checking the child's weight daily is a priority action because weight changes can indicate fluid retention or loss, which can affect kidney function. Regular weight checks can help guide treatment decisions and monitor the effectiveness of interventions. Educating the parents about potential complications is important, but it is not the priority action. The nurse's priority should be to assess the child's condition and intervene to prevent complications.