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 A
Explanation
A. Hypotension is the most critical finding in dehydration, as it indicates severe fluid loss and can lead to shock. Immediate intervention is required to address the circulatory compromise.
B. Tachypnea is a compensatory response to dehydration and may not require as immediate attention as hypotension.
C. Hyperpyrexia (high fever) can occur in gastroenteritis but is less urgent compared to hypotension.
D. Skin breakdown is a concern in dehydrated patients, but hypotension poses a more immediate threat to life.
Correct Answer is B
Explanation
A. Encouraging large amounts of fluids may not be effective in preventing nausea and vomiting and can worsen dehydration if the child is unable to keep fluids down.
B. Administering an antiemetic 30 minutes to 1 hour before chemotherapy is the most effective strategy for preventing nausea and vomiting. This proactive approach helps to prevent the symptoms before they occur.
C. NPO until symptoms subside is not appropriate because it can lead to dehydration and malnutrition.
D. Administering an antiemetic after symptoms begin is reactive rather than proactive, and it is more effective to prevent symptoms from occurring.
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