Exhibits
Click to highlight the findings that indicate that the client's condition is improving. To deselect a finding, click on the finding again.
1400:
Client admitted to the medical-surgical unit at 1200 today. Alert and orientated x4, heart and lung sounds clear. Client urinating 100 mL/hour. Client is tolerating soft diet and oral fluids. Bowel sounds are hyperactive in all 4 quadrants. Bilateral pedal pulses 2+. Blood glucose 310 mg/dL (74 to 106 mg/dL)
1400:
Temperature 36.8° C (98.2° F) Pulse rate 84/min Respiratory rate 16/min
Blood pressure 106/76 mm Hg Oxygen saturation 96% on room air
Client urinating 100 mL/hour
Client is tolerating soft diet and oral fluids
Bilateral pedal pulses 2+
Blood glucose 310 mg/dL (74 to 106 mg/dL)
Pulse rate 84/min
Respiratory rate 16/min
Blood pressure 106/76 mm Hg
Oxygen saturation 96% on room air
admitted to the medical-surgical unit at 1200 today
Alert and orientated x4
The Correct Answer is ["A","B","C","D","E","F","G"]
Blood glucose 310 mg/dL (74 to 106 mg/dL)
The initial blood glucose level was 468 mg/dL, indicating severe hyperglycemia, likely due to diabetic ketoacidosis (DKA). The decrease to 310 mg/dL suggests that the insulin therapy is starting to bring the blood glucose levels down towards normal range. This reduction is a positive sign of response to treatment.
Client urinating 100 mL/hour
This indicates improved kidney function compared to the initial presentation where the client reported frequent urination and nausea. Adequate urine output (typically more than 30 mL/hour) is crucial in managing DKA as it signifies improved renal perfusion and clearance of ketones and glucose from the blood.
Client is tolerating soft diet and oral fluids
This indicates improvement in gastrointestinal function and resolution of nausea, which is consistent with the ondansetron administration for nausea control. It also suggests that the client's appetite and overall condition are improving.
Bilateral pedal pulses 2+
Initially, the pulses were 1+, indicating poorer peripheral perfusion. Bilateral pedal pulses becoming 2+ suggest improved circulation, likely due to the correction of acidosis and hydration status with fluid and electrolyte
Blood pressure
The improvement in the blood pressure indicates that the client is out of the dehydration state caused by DKA.
Pulse rate
Resolution of tachycardia is a good indicator of improved hydration status
Respiratory rate
The decrease in respiratory rate is an indicator of improving acidosis and resolution of Kussmaul breathing common in DKA.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Edema is expected in the initial hours and days following major burns and can be particularly pronounced in full-thickness burns due to extensive tissue damage and inflammation.
A Initially, full-thickness burns may not be as painful due to nerve damage; however, surrounding areas with partial-thickness burns or areas where nerve endings are intact can be extremely painful. The absence of severe pain at the site of full-thickness burns is common initially due to nerve damage, but pain management is crucial as inflammation progresses.
B. Full-thickness burns typically involve destruction of the entire epidermis and dermis, leading to the absence of blisters. Blisters are characteristic of partial-thickness burns, where the epidermis is partially damaged but not completely destroyed.
C. Epithelialization refers to the process of new skin cells migrating and covering the wound, a process that occurs during the later stages of wound healing. In the acute phase of full-thickness burns, epithelialization does not occur because the skin layers are completely destroyed. This process starts later once the wound has been adequately debrided and begins to heal.
Correct Answer is D
Explanation
A Hydrogen peroxide can be too harsh and irritating to inflamed oral mucosa. It may further aggravate mucositis and delay healing. Therefore, it is not appropriate to recommend rinsing with hydrogen peroxide for a client with mucositis.
B. Brushing for 60 seconds is not enough.
C. Dentures can exacerbate mucositis by causing friction and pressure on the gums and oral mucosa. To reduce irritation, clients should remove dentures when not eating to give their gums and oral tissues a chance to rest and recover.
D. Flossing can help remove food particles and plaque from between the teeth, which could otherwise contribute to infection.
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