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 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.

A. Monitor the client's vital signs once every hour. B. Elevate the head of the client's bed to a 45° angle. C. Restrict the client's fluid intake. D. Instruct the client not to bend the affected leg.

Correct Answer is D

Explanation

D. Instructing the client not to bend the affected leg helps prevent accidental dislodgement of the arterial sheath or catheter and reduces the risk of bleeding or hematoma formation at the insertion site.

A While monitoring vital signs is important, doing so once every hour is not specified as a standard post- procedure action.

B. Elevating the head of the bed to a 45° angle and restricting fluid intake are not standard care measures following this procedure and could potentially be contraindicated.

C. This action is not typically necessary following a cardiac catheterization unless there are specific indications such as fluid overload or impaired renal function

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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

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

A nurse is caring for a client immediately following a cardiac catheterization through the right femoral artery. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who has a chest tube. The client asks why the fluid in the water-seal chamber rises and falls. Which of the following statements should the nurse make?

A nurse is caring for a client who has a contusion of the brainstem and reports thirst. The client's urinary output was 4,000 mL over the past 24 hr. The nurse should anticipate a prescription for which of the following IV medications?

Exhibits The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up:

A nurse is caring for a client who has a sealed radiation implant. Which of the following actions should the nurse take?

A nurse is assessing a client who has heart failure and a new prescription for metoprolol. Which of the following findings should the nurse identify as an adverse effect of the medication?

A nurse is caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings should the nurse identify as an indication that the medication was effective?

A nurse is providing discharge teaching for a client who is receiving treatment for genital herpes. Which of the following statements by the client indicates effectiveness of the teaching?

A nurse is teaching a client who has a new diagnosis of rheumatoid arthritis. Which of the following statements should the nurse include in the teaching?

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.