A nurse is collecting data from a client who has diabetes mellitus.
Which of the following findings indicates that the client is experiencing DKA?

Confusion

Polydipsia

Rapid pulse

Clammy skin

Answer and Explanation

Correct Answer : A,B,C

Choice A rationale:

Confusion can be a symptom of Diabetic Ketoacidosis (DKA). DKA is a serious complication of diabetes that occurs when your body produces high levels of blood acids called ketones. The condition develops when your body can’t produce enough insulin. Insulin normally plays a key role in helping sugar (glucose) — a major source of energy for your muscles and other tissues — enter your cells. Without enough insulin, your body begins to break down fat as fuel. This process produces a buildup of acids in the bloodstream called ketones, eventually leading to diabetic ketoacidosis if untreated.

Choice B rationale:

Polydipsia, or excessive thirst, is another common symptom of DKA. High blood sugar levels can cause increased urination, leading to dehydration and an increased feeling of thirst.

Choice C rationale:

A rapid pulse is also a symptom of DKA. This is because the body is trying to compensate for the low amount of fluid in your blood vessels due to dehydration.

Choice D rationale:

Clammy skin is not typically a symptom of DKA. It’s more commonly associated with hypoglycemia (low blood sugar), not hyperglycemia (high blood sugar) which is what occurs in DKA1.

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Correct Answer is D

Explanation

Choice A rationale:

Constipation is not typically associated with hyperthyroidism. In fact, one of the symptoms of hyperthyroidism is increased bowel movement. This is due to the increased metabolic rate caused by the overproduction of hormones from the thyroid gland.

Choice B rationale:

Weight gain is not a common symptom of hyperthyroidism. On the contrary, weight loss is one of the symptoms of this condition. This is because hyperthyroidism speeds up the body’s metabolism, causing increased calorie burning and significant weight loss. Choice C rationale:

Sensitivity to cold is not a symptom of hyperthyroidism. Instead, individuals with hyperthyroidism often have an increased sensitivity to heat. This is due to the increased metabolic rate which can cause excessive sweating and hot flashes.

Choice D rationale:

Frequent mood changes are a common symptom of hyperthyroidism. The overproduction of hormones by the thyroid gland can lead to symptoms such as irritability and restlessness. Additionally, other symptoms such as difficulty sleeping can also contribute to mood changes.

A. Hold the drug, and administer 4 hours later. B. Administer the vancomycin as ordered. C. Hold the drug, and notify the prescriber. D. Repeat the test to verify results.

Correct Answer is C

Explanation

Choice A rationale:

Holding the drug and administering it 4 hours later is not the appropriate action. The trough vancomycin level of 24 mcg/mL is higher than the recommended range of 10-20 mcg/mL, indicating potential risk for toxicity. Administering the drug later does not address the immediate concern of a high trough level.

Choice B rationale:

Administering the vancomycin as ordered is not the correct action in this case. The trough level is above the recommended range, which could lead to vancomycin toxicity. The nurse should not administer the medication without addressing the high trough level. Choice C rationale:

This is the correct action. The nurse should hold the drug and notify the prescriber because the trough vancomycin level is higher than the recommended range. The prescriber can then make a decision based on this information, which may include adjusting the dose, extending the dosing interval, or ordering additional tests.

Choice D rationale:

While repeating the test to verify results might be done eventually, it should not be the immediate next step. The nurse has a responsibility to ensure patient safety, and with a trough level above the recommended range, the priority is to prevent potential toxicity. Therefore, the nurse should hold the drug and notify the prescriber.

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A nurse is collecting data from a client who has diabetes mellitus. Which of the following findings indicates that the client is experiencing DKA?

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data on a patient who has hyperthyroidism. Which of the following symptoms should the nurse anticipate the patient to report?

Correct Answer is D

Explanation

The nurse checks the patient’s laboratory work prior to administering a dose of vancomycin and finds that the trough vancomycin level is 24 mcg/mL. What will the nurse do next?

Correct Answer is C

Explanation

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A nurse is collecting data from a client who has diabetes mellitus.
Which of the following findings indicates that the client is experiencing DKA?