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. Insert the IV catheter: Establishing IV access is necessary for medication administration, but it should follow the ECG to confirm the diagnosis and direct further treatment.

B. Initiate oxygen therapy: While oxygen can be important to increase myocardial oxygenation, it is typically administered after confirming the MI. Current guidelines recommend oxygen therapy primarily for patients with oxygen saturation below 90%.

C. Attach the leads for a 12-lead ECG: The 12-lead ECG is the most critical initial step as it is the definitive diagnostic tool for identifying and confirming a myocardial infarction (MI). It helps to determine the type and extent of the MI, which guides subsequent treatment decisions. Quick identification of an MI is crucial for timely intervention.

D. Obtain a blood sample: Blood tests, including cardiac enzyme measurements, are important but secondary to the ECG in the acute phase for diagnosing an MI.

A. Chronic cough B. Sputum production C. Dyspnea D. Wheezing E. Chest tightness

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

Explanation

A. Chronic cough: Chronic cough is a hallmark symptom of COPD. It results from inflammation and increased mucus production in the airways, leading to a persistent cough that often produces sputum.

B. Sputum production: Sputum production is common in COPD due to chronic bronchitis, which is part of the disease spectrum. It reflects the ongoing inflammation and irritation of the airways.

C. Dyspnea: Dyspnea, or shortness of breath, is a primary symptom of COPD. It occurs due to airflow limitation and reduced lung capacity, making it difficult for the patient to breathe, especially during physical activity.

D. Wheezing: Wheezing can occur in COPD as a result of narrowed airways due to inflammation and mucus build-up. It is a common but not universally present symptom.

B. Sputum production: Sputum production is common in COPD due to chronic bronchitis, which is part of the disease spectrum. It reflects the ongoing inflammation and irritation of the airways.

D. Wheezing: Wheezing can occur in COPD as a result of narrowed airways due to inflammation and mucus build-up. It is a common but not universally present symptom.

E. Chest tightness: Chest tightness is also a common symptom of COPD, reflecting the discomfort and difficulty in breathing caused by the constriction and inflammation of the airways.

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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

A nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction. Which of the following prescriptions should the nurse take first?

Correct Answer is C

Explanation

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

Explanation

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