Page 959 - Saunders Comprehensive Review For NCLEX-RN

Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Pediatrics: Metabolic/Endocrine
Health Problem: Pediatric-Specific: Diabetes mellitus
Priority Concepts: Clinical Judgment; Glucose Regulation
Reference: McKinney et al. (2018), pp. 1268, 1271-1272.

327. Answer: 2

Rationale: Phenylketonuria is a genetic (autosomal recessive) disorder that results
in central nervous system damage from toxic levels of phenylalanine (an essential
amino acid) in the blood. It is characterized by blood phenylalanine levels greater
than 20 mg/dL (1210 mcmol/L); normal level is 0 to 2 mg/dL (0 to 121 mcmol/L). A
result of 1 mg/dL is a negative test result.
Test-Taking Strategy: Eliminate options 3 and 4 first because they are comparable
or alike, indicating no definitive finding. Note that the level identified in the
question is a low level; this should assist in directing you to the correct option.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Pediatrics: Metabolic/Endocrine
Health Problem: Pediatric-Specific: Phenylketonuria
Priority Concepts: Clinical Judgment; Health Promotion
Reference: Hockenberry, Wilson, Rodgers (2017), pp. 292-293.

328. Answer: 4

Rationale: Diabetic ketoacidosis is a complication of diabetes mellitus that
develops when a severe insulin deficiency occurs. Hyperglycemia occurs with
diabetic ketoacidosis. Rehydration is the initial step in resolving diabetic
ketoacidosis. Normal saline is the initial IV rehydration fluid. NPH insulin is never
administered by the IV route. Dextrose solutions are added to the treatment when
the blood glucose level decreases to an acceptable level. Intravenously administered
potassium may be required, depending on the potassium level, but would not be
part of the initial treatment.
Test-Taking Strategy: Focus on the subject, treatment for diabetic ketoacidosis.
Eliminate option 3, knowing that dextrose would not be administered in a
hyperglycemic state. Eliminate option 2 next, knowing that NPH insulin is not
administered by the IV route. Recalling that hydration is the initial treatment in
diabetic ketoacidosis will direct you to the correct option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Planning
Content Area: Pediatrics: Metabolic/Endocrine
Health Problem: Pediatric-Specific: Diabetes mellitus
Priority Concepts: Clinical Judgment; Glucose Regulation
Reference: McKinney et al. (2018), pp. 1271-1272.

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