A nurse assesses a patient who is experiencing diabetic ketoacidosis (DKA). Which manifestations would the nurse correlate with DKA? (Select all that apply)

Choice A reason: Delaying the transfusion and notifying the provider is critical, as a fever of 100.7°F suggests possible infection or inflammation. Transfusing blood in a febrile patient risks exacerbating underlying infection or causing transfusion reactions. The provider must evaluate the fever’s cause to ensure safe administration and prevent complications like sepsis or hemolytic reactions.

Choice B reason: Administering an antihistamine and starting the transfusion is inappropriate, as antihistamines address allergic reactions, not fever. A temperature of 100.7°F indicates potential infection, requiring investigation before transfusion. Proceeding without addressing the fever risks worsening an underlying condition or causing transfusion-related complications, making this an unsafe action.

Choice C reason: Administering acetaminophen to reduce fever and starting the transfusion is incorrect, as it masks the fever without identifying its cause. A temperature of 100.7°F may indicate infection, which must be evaluated before transfusion to avoid complications like sepsis. Treating symptoms without investigation compromises patient safety in this scenario.

Choice D reason: Beginning the transfusion as prescribed is unsafe with a fever of 100.7°F, as it may indicate infection or inflammation. Transfusing without investigating the fever risks exacerbating underlying conditions or causing transfusion reactions. Delaying and notifying the provider ensures the cause is addressed, prioritizing patient safety and appropriate management.

Choice A reason: Diarrhea is not a primary feature of acute pancreatitis. While gastrointestinal symptoms like nausea and vomiting occur due to pancreatic inflammation, diarrhea is less common. Pancreatitis typically causes reduced bowel motility from inflammation or ileus, leading to constipation rather than diarrhea, which is more associated with other conditions like gastroenteritis.

Choice B reason: Abdominal guarding is a classic sign of acute pancreatitis, as inflammation causes severe epigastric or left upper quadrant pain, leading to involuntary muscle tensing to protect the area. This response results from peritoneal irritation or pancreatic enzyme leakage, making it a key physical finding in assessing pancreatitis severity and guiding treatment.

Choice C reason: Hyperactive bowel sounds are not typical in acute pancreatitis. Inflammation often causes an ileus, leading to diminished or absent bowel sounds due to reduced gastrointestinal motility. Hyperactive sounds suggest conditions like bowel obstruction, not pancreatitis, where the inflammatory process slows peristalsis, making this finding inconsistent with the diagnosis.

Choice D reason: Ecchymosis in the flank (Grey Turner’s sign) is a hallmark of severe acute pancreatitis, indicating retroperitoneal hemorrhage from pancreatic enzyme leakage or necrosis. Blood tracks to the flank, causing bruising. This sign reflects significant disease severity, often requiring intensive care, and is a critical finding in pancreatitis assessment.

Choice E reason: Black, tarry stools (melena) indicate upper gastrointestinal bleeding, not typically associated with acute pancreatitis. While severe pancreatitis may rarely cause bleeding, melena is more common in conditions like peptic ulcers. Pancreatitis symptoms focus on pain, nausea, and bruising, not gastrointestinal bleeding, making this finding unlikely.

Choice F reason: Left upper quadrant pain radiating to the back is a classic symptom of acute pancreatitis. Pancreatic inflammation causes severe epigastric pain that often radiates to the back due to the pancreas’s retroperitoneal location. This pain pattern, often described as boring or constant, is a key diagnostic feature of pancreatitis.