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The nurse is caring for a patient with diabetes.

Exhibits

The nurse has just completed the on-coming shift assessment for their client. Select the "6" findings that require immediate follow-up

Oxygen saturation

Blurry vision

Blood pressure

Blood glucose

Nausea

Pain level

Fruity odor to breath

Heart rate

Answer and Explanation

Correct Answer : B,C,D,E,G,H

A. Oxygen saturation of 98% on room air is within normal limits and not immediately concerning. There is no sign of respiratory distress or hypoxia that requires acute intervention.

B. Blurry vision may be a sign of acute hyperglycemia affecting ocular perfusion or swelling of the lens, often seen during diabetic ketoacidosis (DKA). Visual changes can be transient but signal metabolic instability that needs monitoring.

C. Blood pressure of 90/54 mmHg is hypotensive, which may indicate dehydration and poor perfusion, common in DKA due to osmotic diuresis. It also raises concern for shock if not treated promptly.

D. Blood glucose displaying “hi” on the glucometer indicates levels likely above 600 mg/dL, pointing toward a hyperglycemic crisis like DKA and requiring immediate insulin and fluid therapy.

E. Nausea is an early symptom of DKA as ketone accumulation and metabolic acidosis irritate the gastrointestinal system. This also increases the risk for further dehydration and electrolyte imbalances.

F. Pain level reported as 0/10 indicates the patient is currently not in discomfort. While headache was mentioned, its absence as a pain concern suggests it is not a critical issue at this moment.

G. Fruity odor to breath is a hallmark of ketone accumulation, indicating ketosis or ketoacidosis. This is a critical red flag that demands prompt insulin and hydration therapy to avoid worsening acidosis.

H. Heart rate of 122 bpm is tachycardia, a compensatory response to dehydration and hypotension in DKA. Persistent tachycardia with low BP is a sign of fluid deficit and early circulatory compromise.

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Free Nursing Study Resources

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

Explanation

Assessment Finding	Improved	No Change	Declined
Blood pressure	✓
Respirations	✓
Hyperglycemia	✓
Temperature			✓
Heart Rate		✓

Rationale:

Blood pressure: Blood pressure increased from 90/58 mmHg at 2000 to 112/60 mmHg at 2100, reflecting hemodynamic stabilization likely due to fluid resuscitation and correction of hypoglycemia. This improvement indicates better cardiovascular status.
Respirations: Respiratory rate decreased from 26 breaths/min at 2000 to 20 breaths/min at 2100, with respiration described as even and unlabored. This suggests resolution of metabolic acidosis and respiratory compensation.
Hyperglycemia: Capillary blood glucose decreased from 420 mg/dL on admission to 120 mg/dL at 2100. This indicates effective glycemic control after insulin therapy and glucose administration.
Temperature: Temperature increased from 98.0°F at 2000 to 100.2°F at 2100, indicating development of fever. This suggests possible infection or inflammatory process is ongoing or worsening.
Heart Rate: No Heart rate remained elevated (118 bpm at 2000 and 120 bpm at 2100) with minimal variation, suggesting persistent sympathetic stimulation or stress response without significant improvement.

A. Heart rate is 54, patient has complained of constipation and poor appetite. B. Patient is anxious and irritable with skin moist and warm C. Nonpitting edema noted in the extremities with thinning hair D. Patient has recently lost over 10 pounds in the last month and has noticed a fine tremor in the hands

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

Explanation

Heart rate is 54, patient has complained of constipation and poor appetite: Myxedema, a severe form of hypothyroidism, causes bradycardia due to decreased metabolism. Constipation and poor appetite occur as slowed metabolism reduces gastrointestinal motility and hunger.
Patient is anxious and irritable with skin moist and warm: Graves Disease causes hyperthyroidism, increasing metabolic rate and sympathetic activity. This leads to anxiety, irritability, and warm, moist skin from increased blood flow and sweating. These findings show the hypermetabolic state of Graves.
Nonpitting edema noted in the extremities with thinning hair: Nonpitting edema results from mucopolysaccharide buildup in hypothyroidism. Thinning hair occurs due to thyroid hormone deficiency affecting hair follicles. These are classic signs of advanced hypothyroidism.
Patient has recently lost over 10 pounds in the last month and has noticed a fine tremor in the hands: Weight loss despite increased appetite is typical of Graves Disease due to elevated metabolism. Fine hand tremors result from increased beta-adrenergic stimulation. These symptoms indicate hyperthyroidism.

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The nurse is caring for a patient with diabetes. Exhibits The nurse has just completed the on-coming shift assessment for their client. Select the "6" findings that require immediate follow-up

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with diabetes. Exhibits For each assessment finding, click to specify if the finding indicates that the client's condition has improved, has not changed, or has declined. Only choose one option for each assessment finding. Each option will be used at least once.

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

Explanation

For each client finding below, click to specify if the finding is consistent with the disease process

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

Explanation

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The nurse is caring for a patient with diabetes.

Exhibits

The nurse has just completed the on-coming shift assessment for their client. Select the "6" findings that require immediate follow-up