A nurse is collecting data from a client who has diabetic ketoacidosis. Which of the following findings should the nurse expect?

Fruity breath odor

Clammy skin

Bounding pulse

Elevated blood pressure

Answer and Explanation

The Correct Answer is A

The correct answer is A. Fruity breath odor. This is caused by the presence of acetone, a byproduct of fat metabolism, in the breath. Diabetic ketoacidosis is a condition where the body cannot use glucose as a fuel source due to insulin deficiency or resistance, and resorts to breaking down fat for energy, resulting in ketone production and acidosis. Clammy skin, bounding pulse and elevated blood pressure are signs of a hyperglycemic hyperosmolar state (HHS), another complication of diabetes that is characterized by severe dehydration and hyperglycemia without significant ketosis or acidosis.

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Correct Answer is C

Explanation

The correct answer is choice c. The restraints are secured with a quick-release knot.

Choice A rationale:

The restraints should never be attached to the side rails of the bed. This can cause injury if the side rails are moved up or down. Instead, restraints should be attached to a part of the bed frame that does not move.

Choice B rationale:

The nurse should be able to insert only two fingers under the secured restraint. If three fingers can be inserted, the restraint is too loose and may not effectively prevent the patient from harming themselves or others.

Choice C rationale:

Securing the restraints with a quick-release knot is correct because it allows for easy and rapid removal in case of an emergency.

Choice D rationale:

The soft pad of the restraint should face the client’s skin to prevent skin irritation and injury. If the soft pad faces away from the skin, it can cause discomfort and potential harm.

A. Tie the gown with the gloves on. B. Tuck the glove cuffs under the gown sleeves. C. Apply the gown before the gloves. D. Push the gown sleeves up to the elbows.

Correct Answer is C

Explanation

The correct answer is B.

Tucking the glove cuffs under the gown sleeves can prevent contamination of clothing and skin by microorganisms that may be present on the gown or gloves. The nurse should apply the gown after washing hands and before putting on gloves, and tie it securely at the neck and waist. The nurse should not push up the gown sleeves, as this can expose skin and clothing to contamination.

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A nurse is collecting data from a client who has diabetic ketoacidosis. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has wrist restraints in place. Which of the following findings indicates that the restraints are applied correctly?

Correct Answer is C

Explanation

A nurse is caring for a client who has Clostridium difficile. When applying a cover gown, which of the following techniques should the nurse use?

Correct Answer is C

Explanation

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