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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?

A.

Fruity breath odor

B.

Clammy skin

C.

Bounding pulse

D.

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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Related Questions

Correct Answer is C

Explanation

The correct answer is C. Open the outermost flap of the sterile kit away from the nurse's body.

Rationale: The nurse should open the outermost flap of the sterile kit away from their body first, as this will prevent contamination of their clothing or hands by touching any part of

the inside surface or contents of the kit. The nurse should then open each side flap by grasping only its outer edge and pulling it toward them. The nurse should then open the flap nearest to them by grasping only its outer edge and pulling it toward them. The nurse should then apply sterile gloves before touching any part of the inside surface or contents of the kit.

Correct Answer is C

Explanation

The correct answer is choice C. Changing a central venous catheter dressing for a client who is receiving IV therapy. Choice A rationale: Instilling ophthalmic ointment typically does not require sterile gloves. Clean technique is sufficient as long as proper hand hygiene is performed to prevent infection. Choice B rationale: Inserting an NG tube requires clean technique, not sterile. The procedure is performed through the nasal passage and esophagus, which are not sterile environments. Choice C rationale: Changing a central venous catheter dressing requires sterile gloves to prevent introducing infection into the bloodstream. Central lines are a direct pathway to the central circulation, making aseptic technique critical to prevent serious infections such as bloodstream infections. Choice D rationale: Administering an IM injection requires clean technique. The skin is cleaned with an antiseptic wipe before the injection, but sterile gloves are not necessary for this procedure.

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