A nurse is collecting data from a client who is experiencing ketoacidosis. Which of the following manifestations should the nurse expect to find?

Hypertension

Fruity breath odor

Protruding eyeballs

Decreased urinary output

Answer and Explanation

The Correct Answer is B

A. Hypertension: Clients experiencing diabetic ketoacidosis (DKA) are more likely to present with hypotension rather than hypertension due to dehydration caused by osmotic diuresis. Volume depletion significantly lowers blood pressure rather than raising it in the setting of DKA.

B. Fruity breath odor: A fruity or acetone-like breath odor is a hallmark sign of DKA. It results from the accumulation of ketones, particularly acetone, in the blood, which the body attempts to eliminate through the lungs, giving the breath its characteristic sweet or fruity smell.

C. Protruding eyeballs: Protruding eyeballs, or exophthalmos, are associated with hyperthyroidism, particularly Graves' disease, not with diabetic ketoacidosis. DKA affects metabolic and acid-base balance but does not cause changes to eye appearance or positioning.

D. Decreased urinary output: In the early stages of DKA, clients usually experience increased urinary output (polyuria) due to osmotic diuresis from hyperglycemia. Decreased output may occur only in the later stages when severe dehydration and kidney compromise develop, but it is not an early expected finding.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A: Image A shows hands with fingers that appear elongated and have widened nail beds. The fingertips look rounded and bulbous, which is characteristic of clubbing. Clubbing often results from chronic hypoxia and is seen in conditions like congenital heart disease, cystic fibrosis, and chronic lung disease.

B: Image B shows normal-appearing fingers with straight nail beds and no signs of bulbous enlargement at the fingertips. This appearance is not consistent with clubbing and represents normal finger structure without signs of chronic hypoxia or circulatory issues.

A. Contact the provider within 48 hr to obtain a prescription for the restraints. B. Remove the restraints from the client's wrists every 2 hr C. Check that one finger will fit between the client's wrists and the restraints. D. Fasten the restraints' ties to the bed's side rails.

Correct Answer is B

Explanation

A. Contact the provider within 48 hr to obtain a prescription for the restraints: A provider’s order for restraints must be obtained immediately or within a very short time frame, usually within 1 hour, depending on facility policy. Waiting 48 hours would be inappropriate and could lead to violation of patient rights.

B. Remove the restraints from the client's wrists every 2 hr: Restraints must be removed at least every 2 hours to assess skin integrity, provide range of motion exercises, and evaluate the continued need for restraints. This practice ensures client safety, prevents complications such as pressure injuries, and respects client dignity.

C. Check that one finger will fit between the client's wrists and the restraints: The correct practice is to ensure that two fingers can fit between the restraint and the skin to prevent circulatory impairment and skin breakdown. One finger would be too tight and could increase the risk of injury.

D. Fasten the restraints' ties to the bed's side rails: Restraints should always be tied to the bed frame, not the side rails. Attaching restraints to movable parts like side rails can cause injury if the rail is lowered or repositioned, leading to unnecessary strain or trauma to the client.

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A nurse is collecting data from a client who is experiencing ketoacidosis. Which of the following manifestations should the nurse expect to find?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a group of clients. Which of the following images indicates a client the nurse should identify as exhibiting clubbing of the fingers?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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