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Exhibits

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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

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","C","D","E"]

Explanation

A. This is a serious complication in DKA, particularly in children, where the shift in osmolality during treatment can lead to fluid shifts into the brain. It can present with neurological deterioration, headache, altered mental status, and even coma.
B. Septic shock
While infection can precipitate DKA, septic shock itself is not a direct complication of DKA. However, DKA can predispose patients to infections due to impaired immune function, dehydration, and hyperglycemia.
C. Cardiac arrhythmias
Electrolyte imbalances, particularly hypokalemia or hyperkalemia (depending on treatment phase), can predispose individuals with DKA to cardiac arrhythmias such as ventricular arrhythmias (e.g., ventricular tachycardia) or atrial fibrillation.
D. Renal failure
Acute kidney injury (AKI) can occur due to dehydration, electrolyte imbalances, and the direct effects of acidosis. However, with prompt and appropriate treatment, renal function typically recovers.
E. Hypotension
Dehydration and volume depletion are common in DKA due to osmotic diuresis and fluid loss. This can lead to hypovolemic shock and hypotension if not adequately managed with fluid resuscitation.
F Respiratory alkalosis
DKA is associated with metabolic acidosis, not respiratory alkalosis. The body compensates for acidosis by increasing respiratory rate (Kussmaul respirations) to blow off CO2 and normalize pH, but this does not lead to respiratory alkalosis.

A. A client who has a score of 0 on the NIH Stroke Scale following a transient ischemic attack B. A client who has a headache following a grade 1 concussion C. A client who has a score of 10 on the Glasgow Coma Scale following a motor vehicle crash D. A client who has experienced brain death and is awaiting organ procurement

Correct Answer is C

Explanation

C. Clients with this score may have altered consciousness and require close monitoring for changes in neurological status, respiratory function, and other complications. Placing this client closest to the nurses' station allows for prompt assessment and intervention if there is deterioration or emergent need.

A Clients with a score of 0 are generally stable and may not require immediate or intensive monitoring. Therefore, this client may not need to be placed closest to the nurses' station unless there are other medical considerations.

B. A grade 1 concussion is considered mild, and while the client may have symptoms such as headache, they are typically stable with minimal risk of deterioration. Monitoring for worsening symptoms is important, but this client may not require immediate proximity to the nurses' station unless symptoms worsen unexpectedly.

D. Clients who are brain dead and awaiting organ procurement are typically stable in terms of neurological status as they are no longer responsive. This client may not necessarily need to be closest to the nurses' station unless specific care needs arise.

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Naxlex Comprehensive Predictor Exams

ExhibitsThe nurse is caring for the client in the ED. The nurse understands that the client is at risk of developing which of the following complications? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

A charge nurse on a neurological unit is making room assignments for a group of clients. Which of the following clients should the nurse assign to the room closest to the nurses' station?

Correct Answer is C

Explanation

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A nurse on a medical-surgical unit is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement?

A nurse is caring for a client in the ICU. The client's ECG monitor tracing reveals sinus bradycardia and S-T segment elevation. The client reports shortness of breath and feeling dizzy and faint. Which of the following medications should the nurse administer?

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