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 C
Explanation
A. While the nurse is required to report, it is not the supervisor’s decision. The nurse should clarify that they are the mandated reporter.
B. Deferring the explanation to the supervisor avoids the nurse’s responsibility. The nurse should directly explain their duty.
C. Nurses are mandated reporters and are legally required to report suspected child abuse. This response is appropriate as it aligns with the nurse’s professional and legal responsibilities.
D. The nurse should address the issue, not refer to the provider for an explanation of their actions.
Correct Answer is A
Explanation
A. Acute rheumatic fever can cause carditis, which may lead to heart murmurs, tachycardia, or heart failure. Assessing heart sounds is a priority to identify potential complications.
B. Joint pain is an important concern in acute rheumatic fever, but the immediate priority is assessing for signs of carditis or heart complications.
C. An erythematous rash is a characteristic of acute rheumatic fever but is less critical to address immediately compared to potential cardiac involvement.
D. Parental anxiety should be addressed, but the priority is assessing the child’s physical condition, particularly the heart.
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