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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["50 "]
Explanation
The question is about calculating the volume of phenytoin oral solution that the nurse should administer per dose. The client is prescribed 250 mg of phenytoin and the available solution has a concentration of 25 mg/5 mL.
Let’s calculate the volume step by step:
Step 1: Identify the prescribed dose and the concentration of the available medication. The prescribed dose is 250 mg and the concentration of the available medication is 25 mg/5 mL.
Step 2: Set up the calculation. We want to find out how many mL correspond to the prescribed dose. We can set up the calculation as follows: (Prescribed dose ÷ Concentration) × Volume.
Step 3: Substitute the known values into the calculation. This gives us: (250 mg ÷ 25 mg/5 mL).
Step 4: Perform the division operation first due to the order of operations (BIDMAS/BODMAS). This gives us: (250 mg ÷ 5 mg/mL).
Step 5: Perform the final calculation. This gives us: 50 mL.
So, the nurse should administer 50 mL of the phenytoin oral solution per dose.
Please note that this calculation assumes that the prescribed dose (250 mg) is to be administered in one go. If the dose is to be split over the day, the volume to be administered would change accordingly.
Correct Answer is C
Explanation
The correct answer is Choice C.
Let’s go through the calculation step by step:
Step 1: Identify the order and the available medication. The order is for dexamethasone (Decadron) 6mg IM. The available stock is dexamethasone 4mg/1ml in a 5ml multidose vial.
Step 2: Determine the amount of medication needed to fulfill the order. This is done by dividing the ordered amount by the concentration of the available medication.
So, we have:
Step 2 Calculation=Concentration of Available MedicationOrdered Amount Substituting the given values: Step 2 Calculation=4 mg/mL6 mg Step 3: Perform the calculation.
Step 3 Calculation=1.5 mL
So, the nurse will prepare 1.5 mL of this medication.
Now, let’s discuss the rationales for each choice:
Choice A rationale:
75 mLs is not the correct amount. This would be a significantly larger dose than ordered, which could lead to an overdose.
Choice B rationale:
5 mLs is not the correct amount. This would also be a larger dose than ordered, which could lead to an overdose.
Choice C rationale:
1.5 mLs is the correct amount. This is calculated by dividing the ordered dose (6 mg) by the concentration of the available medication (4 mg/mL).
Choice D rationale:
15 mLs is not the correct amount. This would be a significantly larger dose than ordered, which could lead to an overdose.
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