A nurse is caring for a client in the emergency department.

For each assessment finding, click to specify if the assessment finding is consistent with diabetic ketoacidosis (DKA) or hyperglycemic-hyperosmolar state (HHS). Each finding may support more than 1 disease process.

Blood glucose greater than expected reference range

Skin turgor

Urine ketones

Creatinine greater than expected reference range

Blood pH

Answer and Explanation

The Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"A,B"},"E":{"answers":"A"}}

• Blood glucose greater than expected reference range: Both DKA and HHS present with significant hyperglycemia. In DKA, glucose is typically moderately elevated (250–600 mg/dL), while HHS usually shows extreme hyperglycemia (>600 mg/dL). Hyperglycemia is a hallmark finding in both conditions, driving osmotic diuresis and dehydration.

• Skin turgor: Dehydration from osmotic diuresis is common in both DKA and HHS, resulting in poor skin turgor. Fluid loss occurs due to polyuria and inadequate intake, contributing to hypotension, tachycardia, and electrolyte imbalances in both conditions.

• Urine ketones: Urine ketones are characteristic of DKA due to lipolysis and ketogenesis caused by insulin deficiency. HHS typically has minimal to absent ketone production because some insulin is present, preventing significant fat breakdown.

• Creatinine greater than expected reference range: Elevated creatinine occurs in both DKA and HHS due to dehydration and pre-renal azotemia from hypovolemia. This reflects impaired renal perfusion and is a marker for severity of fluid deficit in both conditions.

• Blood pH: Metabolic acidosis (low pH) is a defining feature of DKA due to accumulation of ketoacids. HHS usually maintains a near-normal pH because ketosis is minimal, so acidosis is typically absent or mild.

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Correct Answer is C

Explanation

A. “I seem to be bruising more easily,”: Easy bruising is not a typical adverse effect of lisinopril. Bruising may indicate a hematologic issue or another medication effect, but it is unrelated to ACE inhibitor therapy.

B. "I have to urinate frequently.": Increased urination is not commonly associated with lisinopril. Diuretics, rather than ACE inhibitors, are more likely to cause polyuria. This statement does not indicate an adverse effect of lisinopril.

C. "I have a nagging, dry cough.": A persistent, dry cough is a well-known adverse effect of ACE inhibitors like lisinopril. It occurs due to the accumulation of bradykinin in the respiratory tract, and it can be bothersome enough to require medication adjustment or substitution.

D. "I have a heightened sense of taste.": Altered taste perception is not a common adverse effect of lisinopril. While some medications can affect taste, this is not characteristic of ACE inhibitors and is unlikely to be related to the client’s current therapy.

A. Lung sounds clear on auscultation B. Bounding radial pulse C. Alert and oriented to time, place, and person D. Bowel sounds present in four quadrants on auscultation

Correct Answer is A

Explanation

A. Lung sounds clear on auscultation: Clear lung sounds indicate that pulmonary congestion has decreased, reflecting effective diuresis from bumetanide. In heart failure, fluid accumulation in the lungs causes crackles or rales, so improvement in breath sounds demonstrates the medication is reducing fluid overload.

B. Bounding radial pulse: A bounding pulse is not an expected effect of bumetanide and may indicate fluid shifts or other cardiovascular changes unrelated to diuresis. While monitoring pulse is important, a bounding pulse does not reflect the drug’s effectiveness in relieving heart failure symptoms.

C. Alert and oriented to time, place, and person: Mental status may improve with correction of severe fluid overload or hypoxia, but being alert and oriented is not a direct measure of bumetanide’s effectiveness. Neurological status alone does not confirm diuretic action or fluid removal.

D. Bowel sounds present in four quadrants on auscultation: Presence of bowel sounds indicates gastrointestinal function is intact but does not provide information about the resolution of heart failure symptoms. While important for overall assessment, it is not a measure of the effectiveness of diuretic therapy.

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A nurse is caring for a client in the emergency department. For each assessment finding, click to specify if the assessment finding is consistent with diabetic ketoacidosis (DKA) or hyperglycemic-hyperosmolar state (HHS). Each finding may support more than 1 disease process.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who takes lisinopril for hypertension. Which of the following client statements indicates an adverse effect of the medication?

Correct Answer is C

Explanation

A nurse is preparing to administer bumetanide to a client who has heart failure. Which of the following findings indicates effectiveness of the medication?

Correct Answer is A

Explanation

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A nurse is caring for a client in the emergency department.

For each assessment finding, click to specify if the assessment finding is consistent with diabetic ketoacidosis (DKA) or hyperglycemic-hyperosmolar state (HHS). Each finding may support more than 1 disease process.