A nurse is monitoring a client who has diabetes mellitus and a glucose level of 384 mg/dl. (74 to 106 mg/dL). Which of the following findings should the nurse identify as an indication of metabolic acidosis?
Positive Trousseau's sign
Dizziness upon standing
Tingling of the fingers
Increased respiratory rate
The Correct Answer is D
Choice A Reason:
Positive Trousseau's sign is incorrect. Trousseau's sign is associated more with calcium imbalances, particularly hypocalcemia, and is assessed by inflating a blood pressure cuff on the arm to induce carpal spasm. It's not a specific indicator of metabolic acidosis related to high glucose levels in diabetes mellitus.
Choice B Reason:
Dizziness upon standing is incorrect. Dizziness upon standing, also known as orthostatic hypotension, is more commonly associated with blood pressure changes upon position changes. While it can occur in various conditions, it's not a specific indicator of metabolic acidosis in this context.
Choice C Reason:
Tingling of the fingers is incorrect. Tingling sensations, known as paresthesia, can occur due to various reasons, including nerve damage related to chronic high blood sugar levels in diabetes (diabetic neuropathy). However, it's not a direct and specific indicator of metabolic acidosis caused by high glucose levels in diabetes mellitus.
Choice D Reason:
Increased respiratory rate is correct. Metabolic acidosis in a diabetic individual can trigger compensatory mechanisms, such as increased respiratory rate (Kussmaul respirations), as the body tries to eliminate excess acids through respiration to help regulate the acid-base balance. This increased respiratory rate is an attempt to blow off carbon dioxide (a potential acidic byproduct) and decrease the acidity in the blood.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Administering enemas 2 days before the procedure. Enemas are not typically the primary method of bowel preparation for a colonoscopy. Healthcare providers often recommend specific bowel preparation solutions or laxatives that are more effective in thoroughly cleansing the colon.
Choice B Reason:
This is a standard bowel preparation instruction for colonoscopy to ensure a clear view of the colon during the procedure.
Choice C Reason:
This is not necessary for a colonoscopy. A clear liquid diet for a shorter period, usually 12-24 hours, is sufficient.
Choice D Reason:
Expect the provider to schedule another procedure to remove any polyps. While identifying and removing polyps is part of the objective of a colonoscopy, scheduling another procedure specifically for polyp removal isn't usually discussed beforehand. Polyp removal is often performed during the colonoscopy procedure if any are found.
Correct Answer is B
Explanation
Choice A Reason:
"I can take my partner outside of the room as long as they wear a mask."MRSA contact precautions typically involve limiting the spread of the bacteria. Taking the partner outside the room while wearing a mask might not be sufficient for infection control, as MRSA can spread through direct contact with surfaces. This statement might not indicate a full understanding of MRSA precautions.
Choice B Reason:
"I will wash my hands as soon as I leave the room. “Hand hygiene is a crucial component of infection control for MRSA. Washing hands with soap and water or using alcohol-based hand sanitizer after leaving the room helps prevent the spread of MRSA to oneself or others.
Choice C Reason:
"I will wear a gown when I help my partner take a bath." Wearing a gown during tasks that might involve contact with the patient's bodily fluids or surfaces that might be contaminated is recommended for MRSA precautions. This statement aligns with infection control practices.
Choice D Reason:
"I can reuse unsoiled gloves when I re-enter the room. “Reusing gloves, even if they appear unsoiled, is generally not recommended as it can contribute to the spread of MRSA. Gloves should be disposed of after each use and hands washed thoroughly.
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