A nurse is caring for a school-age child who has diabetes mellitus and was admitted with a diagnosis of diabetic ketoacidosis. When performing the respiratory assessment, which of the following findings should the nurse expect?
Periods of apnea for 20 seconds
Paradoxic respirations of 26/min
Shallow respirations of 10/min
Deep respirations of 32/min
The Correct Answer is D
A. Periods of apnea are not typical for DKA and may indicate other respiratory issues.
B. Paradoxic respirations are abnormal and occur when chest and abdomen move in opposite directions, which is not typically associated with DKA.
C. Shallow respirations are not typical of DKA; they would indicate respiratory depression or other issues.
D. Deep, rapid respirations (Kussmaul respirations) are characteristic of diabetic ketoacidosis (DKA). They occur as the body tries to compensate for acidosis by exhaling more carbon dioxide.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Periods of apnea are not typical for DKA and may indicate other respiratory issues.
B. Paradoxic respirations are abnormal and occur when chest and abdomen move in opposite directions, which is not typically associated with DKA.
C. Shallow respirations are not typical of DKA; they would indicate respiratory depression or other issues.
D. Deep, rapid respirations (Kussmaul respirations) are characteristic of diabetic ketoacidosis (DKA). They occur as the body tries to compensate for acidosis by exhaling more carbon dioxide.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"B"}}
Explanation
|
Assessment Finding |
Improved |
No change |
|
Dyspnea |
✅ |
|
|
Heart rate |
✅ |
|
|
Blood pressure |
✅ |
|
|
Oxygen saturation |
✅ |
|
|
Respiratory rate |
✅ |
|
|
Oral intake |
✅ |
|
|
Lung sounds |
✅ |
Rationale:
Improved:
Heart rate and blood pressure are slightly improved by 1930, likely due to the medications (furosemide, enalapril) helping manage fluid retention and blood pressure.
Oral intake has improved, but monitoring of this is critical given the recent lack of eating for several days.
No change:
Dyspnea remains unchanged, since the adolescent is still dyspneic with activity.
Lung sounds remain unchanged, indicating that there may still be some wheezing or fluid buildup in the lungs.
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