A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which of the following findings would the nurse expect to note as confirming this diagnosis?
Elevated glucose and low plasma bicarbonate.
Decreased urine output.
Increased respirations and an increase in pH.
Coma.
The Correct Answer is A
Choice A rationale: Diabetic ketoacidosis (DKA) is a severe complication characterized by hyperglycemia, metabolic acidosis, and ketosis. Elevated glucose levels (typically >250 mg/dL) result from insufficient insulin. The body then breaks down fat for energy, producing ketones which lower the blood pH, resulting in metabolic acidosis. The expected finding is a low plasma bicarbonate level (normal range 22-29 mEq/L) reflecting the metabolic acidosis.
Choice B rationale: Decreased urine output is an incorrect finding. In DKA, hyperglycemia leads to osmotic diuresis, where excess glucose pulls water out of the body, leading to polyuria (increased urine output) and dehydration. The kidneys attempt to excrete the excess glucose and ketones, resulting in frequent and copious urination.
Choice C rationale: Increased respirations (Kussmaul respirations) are a compensatory mechanism for metabolic acidosis, but they lead to a decrease in pH, not an increase. The deep, rapid breathing attempts to blow off carbon dioxide, a form of carbonic acid, to raise the pH back to the normal range of 7.35-7.45.
Choice D rationale: While coma can be a late and severe complication of DKA, it is not a confirming diagnostic finding. DKA is confirmed by the specific biochemical triad of hyperglycemia, ketonemia/ketonuria, and metabolic acidosis. Patients are often awake and responsive in the early stages, experiencing symptoms like nausea, abdominal pain, and lethargy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.8"]
Explanation
Determine the volume of heparin to administer.
The ordered dose is 4000 units and the available concentration is 5000 units/mL.
The calculation is 4000 units ÷ (5000 units/mL) = 0.8 mL.
The nurse will administer 0.8 mL of heparin for this dose.
Correct Answer is A
Explanation
Choice A rationale: An external insulin pump is a device designed to mimic the normal function of the pancreas. It provides a continuous, basal infusion of rapid-acting or regular insulin subcutaneously to maintain a steady blood glucose level. The client can then manually administer a bolus dose before meals to cover the carbohydrate intake, providing greater flexibility and precise glucose management.
Choice B rationale: Insulin pumps use rapid-acting or regular insulin, not NPH insulin. NPH is an intermediate-acting insulin, and its delayed and prolonged action is not suitable for the precise, continuous, and meal-time dosing regimen of an insulin pump. Pumps require fast-acting insulin to manage immediate glucose fluctuations.
Choice C rationale: Insulin pumps are external devices and are not surgically attached to the pancreas. They are worn on the body and deliver insulin into the subcutaneous tissue through a small catheter. The pancreas is an internal organ, and this type of surgical intervention is not a feature of standard insulin pump therapy.
Choice D rationale: The pump uses rapid-acting or regular insulin, not NPH insulin. While it does provide a continuous infusion, the client still needs to manually monitor their blood glucose levels and adjust their bolus doses accordingly. The pump itself does not continuously monitor blood glucose levels without an integrated continuous glucose monitor (CGM) system, which is a separate but often used device.
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