Exhibits

For each assessment finding, click to specify if the assessment finding is consistent with diabetic ketoacidosis (DKA) or hyperglycemic-hyperosmolar state (HHS). Each finding may support more than 1 disease process.

Urine ketones

Creatinine greater than expected reference range

Blood glucose greater than expected reference range

Skin turgor

Blood pH greater than expected reference range

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A,B"},"E":{"answers":"B"}}

Urine ketones:

They are commonly present in DKA due to the breakdown of fats as an alternative energy source when insulin is insufficient. Ketones in urine are a hallmark sign of DKA.

Ketones may not be present in urine in HHS because insulin levels are sufficient to prevent excessive breakdown of fats. Therefore, urine ketones are more specific to DKA.

Creatinine greater than expected reference range

DKA: In DKA, dehydration and electrolyte imbalances can lead to acute kidney injury (AKI), resulting in elevated creatinine levels.

HHS: Elevated creatinine can also occur in HHS due to severe dehydration and reduced kidney perfusion.

Blood glucose greater than expected reference range:

DKA: Extremely high blood glucose levels (typically >250 mg/dL) are a hallmark of DKA due to insulin deficiency and the resultant inability to transport glucose into cells for energy.

HHS: Similar to DKA, HHS is characterized by extremely high blood glucose levels (often >600 mg/dL). Therefore, elevated blood glucose levels are consistent with both DKA and HHS.

Skin turgor

DKA: Decreased skin turgor is indicative of dehydration, which is common in DKA due to excessive urination (polyuria) and fluid loss.

HHS: Similarly, decreased skin turgor can also be seen in HHS due to profound dehydration caused by excessive hyperglycemia and osmotic diuresis.

Blood pH greater than expected reference range

DKA: DKA is characterized by metabolic acidosis, leading to a decreased blood pH (<7.35). Therefore, a pH greater than expected reference range would not be typical for DKA.

HHS: HHS, on the other hand, is characterized by severe hyperglycemia without significant ketoacidosis. Patients with HHS can have a normal or even elevated blood pH (>7.45) due to compensation mechanisms and absence of significant acidosis.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

The nurse should administer a total 1320ml sodium chloride in the first hour, 880ml each subsequent hour.

Rationale

First Hour Administration

Rate: 15 ml/kg/hr Client's weight: 88 kg

Calculation: 15 ml/kg/hr × 88 kg= 1320ml/hr

Therefore, in the first hour, the nurse should administer 1320 mL of 0.9% sodium chloride.

Subsequent Hour Administration

Rate: 10 ml/kg/hr Client's weight: 88 kg

Calculation: 10 ml/kg/hr × 88kg= 880mls

Therefore, each subsequent hour after the first, the nurse should administer 880 mL of 0.9% sodium chloride.

A. Increase the range of motion rapidly when the CPM machine is used intermittently. B. Store the CPM machine on the floor when not in use. C. Turn the CPM machine off while the client is eating. D. Check settings of the CPM machine every 12 hr.

Correct Answer is C

Explanation

C. The CPM machine should be used during designated therapy sessions as prescribed by the healthcare provider. Turning it off during meals allows the client to focus on eating without interference from the machine.

A The range of motion settings on the CPM machine should be adjusted gradually according to the client's tolerance and prescribed therapy plan. Rapidly increasing the range of motion could cause discomfort, pain, or even injury to the client's knee joint. Therefore, the nurse should not increase the range of motion rapidly.

B Storing the CPM machine on the floor is not ideal because it can increase the risk of contamination or damage to the equipment. The machine should be stored on a clean, stable surface when not in use to prevent accidental damage or exposure to dirt and debris.

D. Regular checks of the CPM machine's settings are important, but every 12 hours may not be frequent enough to ensure the machine is functioning correctly and safely.

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Exhibits For each assessment finding, click to specify if the assessment finding is consistent with diabetic ketoacidosis (DKA) or hyperglycemic-hyperosmolar state (HHS). Each finding may support more than 1 disease process.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Complete the following sentence by using the lists of options. The nurse should administer a total dropdown sodium chloride in the first hour, dropdown each subsequent hour.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

First Hour Administration

Subsequent Hour Administration

A nurse is caring for a client who is using a continuous passive motion (CPM) machine following a total knee arthroplasty. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who is experiencing an increase in intracranial pressure (ICP). The nurse should expect which of the following as an early manifestation of increased ICP?

A nurse is caring for a client who is postoperative and develops respiratory depression after receiving morphine for pain control. Which of the following medications should the nurse expect the provider to prescribe?

A nurse is providing teaching to a client who is to start furosemide therapy for heart failure. Which of the following statements indicates that the client understands a potential adverse effect of this medication?

A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes that the weights are resting on the floor. Which of the following actions should the nurse take?

A nurse is providing discharge teaching to a client who is postoperative following a total hip arthroplasty. Which of the following statements should the nurse make?

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?

A nurse is caring for a client who has diabetes mellitus and has been following a treatment plan for 3 months. Which of the following laboratory results should the nurse monitor to determine long- term glycemic control?

Exhibits The nurse is reviewing the client's medical record. Which of the following findings indicates the client's condition has improved? Select all that apply.

Exhibits

For each assessment finding, click to specify if the assessment finding is consistent with diabetic ketoacidosis (DKA) or hyperglycemic-hyperosmolar state (HHS). Each finding may support more than 1 disease process.