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

Choice A: CPR is important but should be performed in conjunction with defibrillation. Since two defibrillation shocks have already been administered, the next step should be another shock.

Choice B : Obtaining an arterial blood gas sample is not the immediate priority when the client is in ventricular fibrillation. Defibrillation should be continued.

Choice C: Performing the third defibrillation shock is the next appropriate step in the advanced cardiac life support (ACLS) algorithm for ventricular fibrillation.

Choice D: Administering an IV bolus of epinephrine may be part of the ACLS protocol, but it is typically administered after defibrillation attempts.

Correct Answer is ["591"]

Explanation

One ounce is equivalent to 29.57 mL, so 12 ounces of coffee is equal to 354.84 mL. The cup of milk is usually measured as 8 ounces, which is 236.59 mL.

The oatmeal may also contain some fluid, but the amount is not given, so it cannot be counted.

Therefore, the total fluid intake at breakfast is 354.84 + 236.59 = 591.43 mL.

The nurse should document this value in the client's record, rounding it to the nearest whole number, which is 591 mL.

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Naxlex Comprehensive Predictor Exams

Following two defibrillation shocks, the client's electrocardiogram (ECG) continues to indicate ventricular fibrillation (VF). Which intervention should the nurse implement next?

Correct Answer is C

Explanation

The nurse assesses a client's fluid intake at breakfast, which consisted of oatmeal, a cup of milk, and 12 ounces of coffee. How many mL should the nurse document in the client's record? (Enter numerical value only.)

Correct Answer is ["591"]

Explanation

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