The nurse is caring for a client with sepsis. Which intervention would the nurse include to monitor for decreased tissue perfusion?

Evaluate pupil reactions every shift

Assess temperature every 4 hours

Monitor for cyanosis

Check reflexes

Answer and Explanation

The Correct Answer is C

Choice A reason: Evaluating pupil reactions every shift is important for neurological assessment but is not directly related to monitoring tissue perfusion.

Choice B reason: Assessing temperature every 4 hours is a standard monitoring procedure for sepsis but does not specifically address tissue perfusion.

Choice C reason: Monitoring for cyanosis is a direct method to assess tissue perfusion. Cyanosis, a bluish discoloration of the skin, indicates poor oxygenation and is a sign of decreased tissue perfusion.

Choice D reason: Checking reflexes is part of a neurological assessment and, while important, it does not directly monitor tissue perfusion.

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Correct Answer is D

Explanation

Choice A reason: A pH of 7.48 is above the normal range (7.35–7.45), indicating a state of alkalosis, not acidosis. A PaCO2 of 31 mm Hg is below the normal range (35–45 mm Hg), which could indicate respiratory alkalosis if it were the primary disorder. An HCO3 level of 26 mEq/L is within the normal range (22–26 mEq/L) and does not suggest metabolic acidosis. Therefore, this choice does not reflect the metabolic acidosis seen in diabetic ketoacidosis (DKA).
Choice B reason: A pH of 7.42 is within the normal range, and a PaCO2 of 39 mm Hg is also within the normal range, suggesting neither acidosis nor alkalosis. An HCO3 level of 25 mEq/L is within the normal range and does not indicate the metabolic acidosis characteristic of DKA. Thus, this choice does not match the expected ABG results for DKA.
Choice C reason: A pH of 7.34 is just below the normal range, indicating a slight acidosis1. A PaCO2 of 40 mm Hg is within the normal range, suggesting that the primary issue is not respiratory. An HCO3 level of 21 mEq/L is slightly below the normal range, which could suggest a mild metabolic acidosis. However, the changes are not as pronounced as typically seen in DKA, where more significant acidosis is expected.
Choice D reason: A pH of 7.17 is significantly below the normal range, indicating severe acidosis1. A PaCO2 of 69 mm Hg is well above the normal range, which would usually suggest respiratory acidosis. However, in the context of DKA, a compensatory respiratory alkalosis often occurs, and the elevated PaCO2 may indicate a mixed acid-base disorder. An HCO3 level of 25 mEq/L is within the normal range, but given the low pH, it suggests that the body has been compensating for an acid-base disturbance. This choice most closely aligns with the metabolic acidosis and the compensatory respiratory changes expected in DKA.

A. Tachycardia B. Intolerance to cold C. Weight loss D. Fine tremors of fingers and hands

Correct Answer is B

Explanation

Choice A reason: Tachycardia, or rapid heart rate, is typically a symptom of an overdose of levothyroxine, not an underdose.

Choice B reason: Intolerance to cold is a common symptom of hypothyroidism, which occurs when the thyroid hormone levels are too low, indicating that the levothyroxine dose may be insufficient.

Choice C reason: Weight loss is more commonly associated with hyperthyroidism or an excessive dose of levothyroxine.

Choice D reason: Fine tremors of fingers and hands are also more indicative of hyperthyroidism or too high a dose of levothyroxine.

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The nurse is caring for a client with sepsis. Which intervention would the nurse include to monitor for decreased tissue perfusion?

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Naxlex Comprehensive Predictor Exams

The nurse is reviewing arterial blood gas (ABG) results for a client with diabetic ketoacidosis. Which result is consistent with this diagnosis?

Correct Answer is D

Explanation

The nurse suspects the client's dose of levothyroxine (Synthroid) is too low when the client displays which symptom?

Correct Answer is B

Explanation

A client's arterial blood gas (ABG) reads: pH 7.18, PaCO2 54 mm Hg, HCO3 26 mEq/L. What condition does the nurse recognize may contribute to the development of this result? Normal values: pH: 7.35-7.45, PaCO2: 35-45 mm Hg, HCO3: 22-26 mEq/L

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