A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse expect?

Blood glucose level below 40 mg/dL

Malignant hypertension

Cheyne-Stokes breathing

Acetone odor to breath

Answer and Explanation

The Correct Answer is D

A. Blood glucose level below 40 mg/dL: Diabetic ketoacidosis (DKA) is characterized by hyperglycemia, typically with blood glucose levels significantly elevated above normal, often exceeding 250 mg/dL. A glucose level below 40 mg/dL would indicate hypoglycemia, which is not a feature of DKA.

B. Malignant hypertension: Malignant hypertension is a condition characterized by extremely high blood pressure and is not directly associated with DKA. DKA primarily involves issues with glucose and acid-base balance rather than hypertension.

C. Cheyne-Stokes breathing: Cheyne-Stokes breathing is a specific pattern of periodic breathing typically seen in severe neurologic conditions or heart failure, not in DKA. DKA is associated with Kussmaul breathing, which is deep and rapid breathing as the body attempts to compensate for metabolic acidosis.

D. Acetone odor to breath: An acetone (fruity) odor to the breath is a classic sign of DKA due to the presence of ketones in the blood and urine. This occurs because the body is breaking down fatty acids for energy, leading to the production of ketones, which are then excreted through the breath and urine.

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Correct Answer is C

Explanation

A. Nitroglycerin: Nitroglycerin is used primarily to manage chest pain and reduce myocardial oxygen consumption by dilating blood vessels. It is typically administered earlier in the management of an acute MI.

B. Oxygen: Oxygen is used to ensure adequate oxygenation, especially if the patient's oxygen saturation is low. However, it is not primarily for managing pain and anxiety.

C. Morphine: After the initial acute phase, morphine is used to manage pain and anxiety associated with an MI. It helps relieve pain, reduce myocardial oxygen demand, and alleviate anxiety, which can contribute to a better overall prognosis.

D. Aspirin: Aspirin is crucial for its antiplatelet effect to reduce clot formation and further damage but does not address pain and anxiety.

A. Regular insulin B. NPH insulin C. Insulin detemir D. Insulin glargine

Correct Answer is A

Explanation

A. Regular insulin: Regular insulin is the preferred insulin for the treatment of diabetic ketoacidosis (DKA) because it has a rapid onset of action and can be administered intravenously. This allows for quick correction of hyperglycemia and ketoacidosis.

B. NPH insulin: NPH (Neutral Protamine Hagedorn) insulin is an intermediate-acting insulin that does not act quickly enough to be effective in the acute management of DKA. It is used for basal glycemic control and not for emergencies.

C. Insulin detemir: Insulin detemir is a long-acting insulin and is not suitable for the acute treatment of DKA. It is used for maintaining basal levels of insulin over a longer period rather than for rapid glucose control.

D. Insulin glargine: Insulin glargine is also a long-acting insulin used to provide a steady level of insulin over 24 hours and is not appropriate for acute management of DKA, which requires rapid-acting insulin.

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A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse expect?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is A

Explanation

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