Page 957 - Saunders Comprehensive Review For NCLEX-RN

331. The nurse should implement which interventions for a child older than 2
years with type 1 diabetes mellitus who has a blood glucose level of 60
mg/dL (3.4 mmol/L)? Select all that apply.
1. Administer regular insulin.

2. Encourage the child to ambulate.
3. Give the child a teaspoon of honey.

4. Provide electrolyte replacement therapy intravenously.

5. Wait 30 minutes and confirm the blood glucose reading.

6. Prepare to administer glucagon subcutaneously if
unconsciousness occurs.

Answers

323. Answer: 4

Rationale: Hypoglycemia is a blood glucose level less than 70 mg/dL (4 mmol/L)
and results from too much insulin, not enough food, or excessive activity. An extra
snack of 15 to 30 g of carbohydrates eaten before activities such as soccer practice
would prevent hypoglycemia. A small box of raisins or a cup of orange juice
provides 15 to 30 g of carbohydrates. The child or parents should not be instructed to
adjust the amount or time of insulin administration. Meal amounts should not be
doubled.
Test-Taking Strategy: Use general medication guidelines to eliminate options 2
and 3 first, noting that they are comparable or alike and indicate changing the
amount of insulin or time of administration. From the remaining options, recalling
the definition of hypoglycemia and its manifestations and associated treatment will
direct you to the correct option.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Pediatrics: Metabolic/Endocrine
Health Problem: Pediatric-Specific: Diabetes mellitus
Priority Concepts: Glucose Regulation; Health Promotion
Reference: McKinney et al. (2018), p. 1267.

324. Answer: 3

Rationale: When the child is sick, the mother should test for urinary ketones with
each voiding. If ketones are present, liquids are essential to aid in clearing the
ketones. The child should be encouraged to drink liquids. Bringing the child to the
clinic immediately is unnecessary. Insulin doses should not be adjusted or changed.
Test-Taking Strategy: Use general medication guidelines. Eliminate options 1 and
4, noting that they are comparable or alike. Recall that insulin doses should not be

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