ATI PN Nursing Care of Children 2020 with NGN II Proctored Exam
A nurse in a clinic is collecting data from an adolescent who has type 1 diabetes mellitus.Which of the following findings is the priority for the nurse to report?
Explanation & Rationale
Choice A reason: A blood glucose level of 220 mg/dL is elevated and should be addressed, but it may not be an immediate priority compared to the presence of Kussmaul respirations. Choice B reason. Correct. Kussmaul respirations are a sign of diabetic ketoacidosis (DKA), a severe complication of diabetes. This requires immediate attention and intervention. Choice C reason: Vomiting is a concerning symptom, but it may not be as immediately life-threatening as Kussmaul respirations. Choice D reason: Frequent urination is a common symptom of diabetes, but it may not require immediate intervention unless it is accompanied by other severe symptoms.
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