A client is admitted with diabetic ketoacidosis (DKA). Upon admission, the client was drowsy and nauseated with reports of a headache. An hour after admission, the practical nurse (PN) is assisting with the care of the client. Which finding is most important for the PN to report to the charge nurse?

Urine appears very dilute.

Client is not responsive.

Breath has a fruity odor.

Skin is flushed and dry.

Answer and Explanation

The Correct Answer is B

Choice A: Urine appearing very dilute may be a concern but is not the most critical finding in a client with diabetic ketoacidosis (DKA).

Choice B: The client not being responsive is the most important finding to report. It may indicate a worsening of the client's condition, possibly related to the progression of DKA or other complications.

Choice C: A fruity odor to the breath is a common symptom of DKA and may have been present upon admission. While it is important to monitor, it is not the highest priority among the choices provided.

Choice D: Flushed and dry skin can be a symptom of DKA but is not the most important finding to report if the client is unresponsive. The client's level of consciousness takes precedence.

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Correct Answer is B

Explanation

Choice A: Fats are an important component of the diet, but they do not typically require specific counting for meal planning in the same way that carbohydrates do for clients with type 1 diabetes mellitus.

Choice B: Carbohydrates are essential for the client to count for each meal and snack. Monitoring carbohydrate intake is a key aspect of managing blood glucose levels in clients with diabetes, especially for those using short-acting insulin to cover meals.

Choice C: Dairy products, while they contain carbohydrates, are not the primary nutrient that requires counting for meal planning in diabetes management.

Choice D: Protein is an important nutrient in the diet, but it does not require the same level of counting and monitoring as carbohydrates for clients with type 1 diabetes mellitus.

A. Solution label. B. Healthcare provider's prescription. C. Medication administration record. D. Measured residual volume. E. Dietician's progress notes. F. Client's identification band.

Correct Answer is ["A","B","F"]

Explanation

Choice A: Confirming information from the solution label is essential to ensure that the correct parenteral nutrition solution is being administered.

Choice B: Confirming the healthcare provider's prescription is critical to verify the type, rate, and duration of the parenteral nutrition therapy, as well as any specific additives or electrolyte requirements.

Choice C: The medication administration record (MAR) is not directly related to parenteral nutrition, so it is not a primary source of information for this specific procedure.

Choice D: Measured residual volume is relevant for enteral nutrition administration but is not applicable to parenteral nutrition.

Choice E: The dietitian's progress notes may provide valuable information about the client's overall nutrition plan but are not the primary source for confirming the immediate administration of a specific parenteral nutrition solution.

Choice F: Confirming the client's identification band is essential to ensure the correct client receives the parenteral nutrition and to prevent errors in administration.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client diagnosed with type 1 diabetes mellitus who uses both short-acting and long-acting insulin adjusted doses throughout the day. Which nutrient is essential for the client to count for each meal and snacks?

Correct Answer is B

Explanation

Before administering a parenteral nutrition solution through a central vein, the nurse should confirm information from which sources? (Select all that apply)

Correct Answer is ["A","B","F"]

Explanation

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