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The nurse is caring for an adolescent with type 1 diabetes mellitus presenting with an HbA1c of 11% (97 mmol/mol), thirst, and blurred vision. Which action should the nurse take first?
- A. Review prior insulin prescriptions.
- B. Obtain point-of-care glucose.
- C. Assess urine for ketones.
- D. Check blood pressure.
Correct Answer: B
Rationale: Obtaining a point-of-care glucose reading is the first step to assess current blood glucose levels, given symptoms suggestive of hyperglycemia.
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During her sports physical examination, 15-year-old female requests oral contraceptives. She explains that she is sexually active and does not want her parents to know. Which action should the nurse take?
- A. Encourage the client to discuss her need for contraceptives with her parents.
- B. Counsel the client about the risks and benefits of using oral contraceptives.
- C. Explain that she needs parental approval to receive contraceptives.
- D. Tell the client how to receive a variety of free oral contraceptives from the clinic.
Correct Answer: B
Rationale: Providing counseling about the risks and benefits of oral contraceptives ensures the client is informed and respects her autonomy and privacy while ensuring she receives necessary information.
The nurse is caring for an infant who was recently diagnosed with a congenital heart defect. Which assessment finding is most important for the nurse to report to the healthcare provider?
- A. Audible heart murmur.
- B. Heart rate of 162 beats/minute.
- C. Poor oral intake and suckling effort.
- D. Weight gain of 2.2 lbs. (1 kg) in the last 48 hours.
Correct Answer: C
Rationale: Poor oral intake and suckling effort indicate feeding difficulties, which can lead to dehydration and poor weight gain, requiring immediate reporting.
A 6-year-old boy with bronchial asthma takes the beta-adrenergic agonist agent albuterol. The child's mother tells the nurse that she uses this medication to open his son's airway when he is having trouble breathing. What is the nurse's best response?
- A. Advise the mother that overuse of the drug may cause chronic bronchitis.
- B. Assure the mother that she is using the medication correctly.
- C. Confirm that the medication helps to reduce airway inflammation.
- D. Recommend that the mother bring the child in for immediate evaluation.
Correct Answer: B
Rationale: Using albuterol to relieve acute breathing difficulties is correct, as it relaxes airway muscles.
The nurse observes a mother giving her 11-month-old ferrous sulfate (iron drops), followed by 2 ounces (60 mL) of orange juice. What should the nurse do next?
- A. Suggest placing the iron drops in the orange juice and then feeding the infant.
- B. Give the mother positive feedback about the way she administered the medication.
- C. Instruct the mother to feed the infant nothing for 30 minutes after giving the iron drops.
- D. Tell the mother to follow the iron drops with infant formula instead of orange juice.
Correct Answer: B
Rationale: Giving orange juice after iron drops enhances iron absorption due to vitamin C, so positive feedback is appropriate.
A newborn with a repaired gastroschisis is transferred to the paediatric unit after several days in the paediatric intensive care unit. The infant is receiving parenteral nutrition and continuous enteral feedings. To maintain normal growth and development of the infant, which action should the nurse include in the plan of care?
- A. Offer a pacifier for non-nutritive sucking.
- B. Use sterile technique during feedings.
- C. Ensure placement of the enteral tube with an abdominal x-ray.
- D. Speak to the healthcare provider about instituting physical therapy.
Correct Answer: A
Rationale: Non-nutritive sucking via a pacifier promotes oral motor skill development, supporting normal feeding behaviors critical for growth.