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 A

Explanation

A. Increased lung expansion: Thoracentesis removes excess fluid from the pleural space, allowing the affected lung to re-expand more fully. Improved lung expansion is an expected therapeutic outcome within a few hours after the procedure, leading to easier breathing and improved ventilation.

B. Rapid, shallow respirations: Rapid, shallow breathing may indicate respiratory distress or complications such as pneumothorax. This is not an expected finding and would require immediate evaluation. Its presence suggests impaired gas exchange rather than improvement after fluid removal.

C. Crepitus at the puncture site: Crepitus indicates subcutaneous emphysema, which can occur if air leaks into the tissue during the procedure. This is an abnormal finding and may signal a pneumothorax or injury to lung tissue, requiring prompt provider notification.

D. Dry, nonproductive cough: While a mild, transient cough may occur immediately after the procedure due to the change in intrathoracic pressure, a persistent or new, dry cough could indicate continued irritation or developing pleural complications, though less critical than the signs of pneumothorax.

A. Anticipate client to be prepped for cardiac catheterization. B. Assist with a continuous heparin infusion. C. Encourage the client to ambulate. D. Anticipate an increased dosage of metoprolol. E. Obtain a prescription for client to be NPO. F. Request a prescription for an antibiotic.

Correct Answer is ["A","B","E"]

Explanation

A. Anticipate client to be prepped for cardiac catheterization: The client’s presentation, including chest pain, ST-segment elevation, elevated troponins, and unstable vital signs, indicates an acute myocardial infarction. Cardiac catheterization is the definitive diagnostic and interventional procedure to restore coronary perfusion.

B. Assist with a continuous heparin infusion: Anticoagulation is a critical component of STEMI management. Heparin is typically started immediately (along with antiplatelet medications like Aspirin, which is already prescribed) to prevent the existing clot from propagating and to prevent the formation of new clots in the coronary arteries.

C. Encourage the client to ambulate: Ambulation is contraindicated in acute myocardial infarction with ongoing chest pain and unstable hemodynamics. Early activity could increase myocardial oxygen demand and worsen ischemia, so the client should remain on bed rest until stabilized and cleared for activity.

D. Anticipate an increased dosage of metoprolol: The client's blood pressure (110/62 mmHg at 12:00) has dropped significantly since the initial presentation and is now borderline low, and the heart rate is still high. Increasing the dosage of a beta-blocker (metoprolol) at this time could cause a dangerous drop in blood pressure and worsen shock.

E. Obtain a prescription for client to be NPO: The client may require urgent procedures such as cardiac catheterization or surgery. Keeping the client NPO prevents aspiration and ensures readiness for potential interventions.

F. Request a prescription for an antibiotic: There is no indication of infection in the client’s presentation or diagnostic results. Administering antibiotics would not address the acute cardiac event and is unnecessary unless new signs of infection develop.

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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 had a thoracentesis 2 hr ago. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

The nurse is reviewing the client's medical record. A nurse is reviewing the client's diagnostic results and vital signs. Which of the following actions should the nurse take? Select all that apply.

Correct Answer is ["A","B","E"]

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.