A nurse is collecting data from a client who develops a fruity breath odor, dry mouth, and extreme thirst. Which of the following additional data should the nurse collect?
Blood glucose using a glucometer
Pupillary reaction to light
Deep tendon reflexes
Liver function laboratory values
The Correct Answer is A
Choice A reason: This is the correct data, because blood glucose using a glucometer can help diagnose and monitor the client's condition, which is likely diabetic ketoacidosis (DKA). DKA is a serious complication of diabetes mellitus, characterized by high blood glucose, ketones in the urine, and acidosis in the blood. Fruity breath odor, dry mouth, and extreme thirst are common signs of DKA.
Choice B reason: This is an irrelevant data, because pupillary reaction to light has no relation to the client's condition, which is likely DKA. Pupillary reaction to light can help assess the client's neurological status and possible brain injury.
Choice C reason: This is an irrelevant data, because deep tendon reflexes have no relation to the client's condition, which is likely DKA. Deep tendon reflexes can help assess the client's neuromuscular function and possible spinal cord injury.
Choice D reason: This is a relevant data, but not the first one. Liver function laboratory values can help assess the client's hepatic function and possible liver damage, which can be a complication of DKA. However, blood glucose using a glucometer is more urgent and specific for the diagnosis and management of DKA.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is an incorrect statement, because the client should avoid any body piercings, tattoos, or other procedures that can cause skin or mucosal trauma and increase the risk of bacterial infection and endocarditis. The client should also seek medical attention if they have a fever or other signs of infection.
Choice B reason: This is a correct statement, because the client should notify their doctor before they have dental procedures, such as cleaning, filling, or extraction, that can cause bleeding and introduce bacteria into the bloodstream. The client may need prophylactic antibiotics to prevent endocarditis.
Choice C reason: This is a partially correct statement, because the client should floss their teeth twice a day as a part of their oral care, but this is not enough to prevent recurrence of endocarditis. The client should also brush their teeth with a soft toothbrush after each meal, use an antiseptic mouthwash, and visit their dentist regularly.
Choice D reason: This is an unnecessary statement, because the client does not need to wear a mask when they go out in public, unless they have a respiratory infection or are exposed to someone who has one. Endocarditis is not transmitted by airborne or droplet routes, but by direct contact with the infected heart valves or blood.
Correct Answer is ["A","C","D"]
Explanation
The correct answer is A, C, D
Choice A reason: Allopurinol is a medication that helps reduce the production of uric acid, which is beneficial for patients with gout and urolithiasis to prevent the formation of uric acid stones.
Choice B reason: While regular exercise is generally beneficial for overall health, it does not have a direct impact on the prevention of uric acid stone formation. Therefore, it is not a specific recommendation for preventing uric acid stone.
Choice C reason: Foods high in purines can increase uric acid levels in the body, leading to the formation of uric acid stones. Limiting the intake of such foods is a key step in preventing uric acid stones.
Choice D reason: Adequate fluid intake is crucial as it helps to dilute the urine, which can prevent the formation of uric acid stones by reducing the concentration of uric acid in the urine.
Choice E reason: Contrary to the statement, lemonade may actually be beneficial in preventing uric acid stones because it contains citrate, which can help prevent stone formation. Citrate can bind to calcium and prevent stone formation, and it also makes the urine less acidic, which can help prevent the formation of uric acid stones.
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