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 C

Explanation

A. A minimally furnished room may be beneficial for safety, but it is not the primary consideration for room assignment.
B. A room with multiple roommates may increase stimulation, which can worsen manic symptoms.
C. A quiet room away from the nurse's station helps reduce environmental stimuli, which can help manage the client's elated state.
D. A bright-colored room near the recreation area may increase sensory stimulation, potentially worsening manic symptoms.

A. Hematocrit. B. Albumin and protein. C. White blood cell count (WBC). D. Electrolytes.

Correct Answer is D

Explanation

Choice A: Hematocrit is a measure of the proportion of blood volume occupied by red blood cells. While it can provide information about anemia or dehydration, it is not typically the first consideration in evaluating numbness and tingling in the extremities.

Choice B: Reviewing albumin and protein levels may be important for assessing overall nutritional status and potential causes of neuropathy but is not the immediate priority when a client reports numbness and tingling in the extremities.

Choice C: White blood cell count (WBC) is important for assessing immune function and the presence of infections. However, it is not typically the primary focus when evaluating numbness and tingling in the extremities.

Choice D: Electrolytes, such as serum sodium and potassium levels, are crucial to review when a client reports numbness and tingling in the extremities. Abnormal electrolyte levels can lead to neurological symptoms, and a review of electrolyte levels can help identify potential causes.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adult client with a diagnosis of bipolar disorder arrives in an elated state on admission to the psychiatric unit. What is the best room assignment the nurse can make for this client?

Correct Answer is C

Explanation

A client reports feeling numbness and tingling in the extremities. Which of the client's serum laboratory values should the practical nurse (PN) review before reporting the finding?

Correct Answer is D

Explanation

The practical nurse (PN) is caring for a 3-month-old male infant two days after a pylorotomy and notices that the infant is restless, grimacing, and drawing his knees to his chest. What action should the PN implement?

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The nurse is planning a fall prevention program for the residents at a long-term care facility. Which intervention is most important in providing a safe environment?

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?

The nurse is preparing a client for ultrasonography of the gallbladder. What should the nurse instruct the client to avoid consuming the night before the test?

During assessment of a 2-month-old infant, the nurse notices a bluish-black discoloration over the lumbosacral area. Which action should the nurse take?