A client with uncontrolled diabetes mellitus develops metabolic acidosis. Which assessment finding related to the imbalance indicates that the client's compensatory mechanisms are working?

Vomiting

Tachycardia

Deep rapid breathing

Watery diarrhea

Answer and Explanation

The Correct Answer is C

A. Vomiting: Vomiting is a common symptom associated with metabolic acidosis but is not a compensatory mechanism. It can lead to further electrolyte imbalances and dehydration.
B. Tachycardia: Tachycardia can occur as a response to acidosis but is not a direct compensatory mechanism for metabolic acidosis.
C. Deep rapid breathing: This is the correct choice. Deep rapid breathing, or Kussmaul respirations, is a compensatory mechanism for metabolic acidosis. It helps to expel carbon dioxide, thereby reducing acidity in the blood.
D. Watery diarrhea: Diarrhea can contribute to electrolyte imbalances and may exacerbate acidosis but is not a compensatory response by the body.

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Correct Answer is B

Explanation

A. Infiltration: Infiltration occurs when IV fluid or medication leaks into the surrounding tissue, typically causing swelling and coolness, but not usually a cord-like vein or a reddened streak.
B. Phlebitis: This is the correct choice. Phlebitis is inflammation of the vein, evidenced by tenderness, burning, swelling, and a reddened streak along the vein. The cord-like vein indicates inflammation.
C. Extravasation: Extravasation involves the leakage of vesicant drugs into surrounding tissue, which can cause severe tissue damage, but usually involves more than just a cord-like vein and reddened streak.
D. Infection: Infection typically presents with more systemic signs like fever and could involve purulent discharge, which is not described in this scenario.

A. Discard the container of formula every 12 hours B. Irrigate the tube with sterile water before administering medications C. Measure & record the residual volume after each feeding D. Keep head of bed elevated 30 degrees

Correct Answer is D

Explanation

A. Discard the container of formula every 12 hours: While this is important for preventing contamination, it does not directly address the risk of aspiration.
B. Irrigate the tube with sterile water before administering medications: This helps maintain tube patency and prevent clogging but does not significantly impact the prevention of aspiration.
C. Measure & record the residual volume after each feeding: Monitoring residuals is crucial for assessing gastric emptying and preventing overfeeding but does not directly prevent aspiration.
D. Keep head of bed elevated 30 degrees: This is the correct choice. Elevating the head of the bed reduces the risk of aspiration by ensuring that gravity helps keep the feeding in the stomach and minimizes the risk of reflux into the esophagus.

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A client with uncontrolled diabetes mellitus develops metabolic acidosis. Which assessment finding related to the imbalance indicates that the client's compensatory mechanisms are working?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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