A nurse is caring for a client diagnosed with diabetic ketoacidosis. Which of the following manifestations should the nurse expect?
Blood glucose level below 40 mg/dL
Acetone odor to breath
Malignant hypertension
Cheyne-Stokes breathing
The Correct Answer is B
A. Blood glucose level below 40 mg/dL is not typical in diabetic ketoacidosis. DKA is characterized by hyperglycemia, and blood glucose levels are usually significantly elevated.
B. Acetone odor to breath is a classic sign of diabetic ketoacidosis. The presence of ketones, including acetone, can result in a fruity or sweet odor to the breath. This is often referred to as "ketone breath."
C. Malignant hypertension is not a typical manifestation of diabetic ketoacidosis. DKA is more commonly associated with dehydration, electrolyte imbalances, and metabolic acidosis.
D. Cheyne-Stokes breathing is not a characteristic respiratory pattern seen in diabetic ketoacidosis. Respiratory changes in DKA are more likely to involve rapid and deep breathing (Kussmaul respirations) as the body attempts to compensate for metabolic acidosis.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Investigate the client's emotional concerns:
While addressing emotional concerns is important, assessing electrolyte imbalances and physiological stability takes precedence in managing an acute exacerbation of ulcerative colitis.
B. Check the client's perianal skin integrity:
Assessing perianal skin integrity is crucial, especially in inflammatory bowel disease, but it might not be the immediate priority compared to evaluating electrolyte imbalances.
C. Obtain a dietary history from the client:
Although dietary history is relevant for managing ulcerative colitis, the urgency lies in assessing and managing potential electrolyte imbalances due to the exacerbation of the condition.
D. Review the client's electrolyte values:
This is the correct action. During an acute exacerbation of ulcerative colitis, the client is at risk of electrolyte imbalances due to diarrhea, dehydration, and potential fluid and electrolyte losses. Promptly reviewing the electrolyte values helps identify any imbalances that might require immediate intervention.
Correct Answer is B
Explanation
A. Level of consciousness:
While assessing the client's level of consciousness is important, it is not the top priority after an EGD procedure unless there are specific signs of neurological distress. Monitoring for signs of sedation or anesthesia recovery is typically part of post-procedure care.
B. Gag reflex:
This is the correct answer. The nurse should prioritize assessing the gag reflex, as the procedure involves passing a flexible tube through the mouth and down the esophagus. Ensuring the return of the gag reflex is essential to prevent aspiration and ensure the client's safety.
C. Pain:
Pain assessment is important, but it is usually addressed after confirming airway protection and ensuring the absence of complications such as bleeding or perforation.
D. Nausea:
While nausea is a possible post-procedure symptom, assessing the gag reflex and monitoring for signs of complications take precedence over managing nausea in the immediate post-procedure period.
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