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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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A: Sitting quietly in her mother's lap may be a sign of shyness or caution in a healthcare setting, but it is not necessarily a typical behavior for a 4-year-old child.

Choice B: Drawing a picture of oneself with facial features is a more advanced skill and may be seen in older preschool-aged children. It is not a typical behavior for a 4- year-old.

Choice C: Talking to an imaginary friend is a normal and developmentally appropriate behavior for a 4-year-old child. Imaginary friends can provide comfort and companionship during times of stress or change.

Choice D: Ignoring other children in the play area may be a sign of shyness or introverted behavior but is not necessarily indicative of normal behavior for a 4-year-old. Social interaction with peers can vary widely among children.

A. Inform the client that oatmeal contains gluten. B. Encourage the client to choose decaffeinated coffee. C. Commend the client for selecting fat free milk. D. Advise the client that too much fruit can irritate the colon.

Correct Answer is A

Explanation

Choice A: Oatmeal is often considered a source of gluten, which should be avoided by individuals with celiac disease. The nurse should inform the client that oatmeal may not be suitable for a gluten-free diet.

Choice B: Encouraging the client to choose decaffeinated coffee is a minor consideration and is not the most important action related to celiac disease.

Choice C: Commending the client for selecting fat-free milk is unrelated to the issue of gluten in the oatmeal and is not the most important action.

Choice D: Advising the client about the potential irritant effects of too much fruit on the colon is not directly related to the issue of gluten in the oatmeal and is not the most important action.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 4-year-old girl returns to the pediatrician's office for a postoperative visit following hospitalization for minor surgery. When observing the child in the waiting area, which behavior should-the nurse consider normal for this age child

Correct Answer is C

Explanation

A client with celiac disease selects a bowl of oatmeal with fresh fruit and skim milk, grapefruit juice, and coffee from the breakfast menu. Which action is most important for the nurse to implement?

Correct Answer is A

Explanation

What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)?

A male child is being prepared for a computed tomography (CT) scan when he begins to have a tonic clonic seizure. His mother is hysterical and is trying to hold the child down. Which action(s) should the nurse take? (Select all that apply.)

The nurse is caring for a client admitted with diabetic ketoacidosis (DKA). Which intervention is most important for the nurse to include in the client's plan of care?

The nurse is helping develop a meal plan based on nutritional guidelines for a 73-year-old client being discharge to home with the client's 65- year-old spouse. Which statement best indicates an understanding of the nutritional guidelines when planning meals by the two spouses?

A middle-aged client newly diagnosed with cholelithiasis is choosing the evening meal.What food choice should the nurse encourage the client to omit?

The practical nurse (PN) overhears a female client with Cushing's syndrome tell her family in a very loud and angry voice to leave her room and not to come back. The response by the PN is based on recognizing which common manifestation of the syndrome?

A client who has a body mass index (BMI) of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurse recommend?

A woman is brought to the labor and delivery unit after delivering a full term infant and the placenta in the hospital parking lot 10 minutes ago. What action should the nurse perform first?