The nurse is caring for a patient with diabetic ketoacidosis (DKA). What clinical manifestations will the nurse anticipate the patient to present? (Select All That Apply)

Kussmaul breathing

Abdominal pain

Positive Trousseau sign

Decreased heart rate

Confusion

Answer and Explanation

Correct Answer : A,B,E

Choice A reason: Kussmaul breathing is a deep, labored breathing pattern that is a compensatory mechanism for metabolic acidosis, commonly seen in diabetic ketoacidosis.

Choice B reason: Abdominal pain is a common symptom in diabetic ketoacidosis due to the metabolic disturbances and dehydration.

Choice C reason: A positive Trousseau sign is associated with hypocalcemia and is not a common manifestation of diabetic ketoacidosis.

Choice D reason: Decreased heart rate is not typical in diabetic ketoacidosis. In fact, patients might present with an increased heart rate due to dehydration and acidosis.

Choice E reason: Confusion is a symptom of diabetic ketoacidosis due to the effects of severe hyperglycemia and metabolic acidosis on the brain.

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Correct Answer is A

Explanation

Choice A reason: Wheezing is a typical sound heard during bronchoconstriction, which occurs in conditions like asthma and COPD. It indicates that the airways are narrowed, causing the characteristic sound.

Choice B reason: Pulmonary edema typically presents with crackles or rales rather than wheezing. Wheezing would not be the primary indication of this condition.

Choice C reason: Hemoptysis refers to coughing up blood and does not typically present with wheezing. It might present with other sounds if there is an underlying lung issue, but wheezing is not specific to it.

Choice D reason: Pneumothorax generally presents with decreased or absent breath sounds on one side, not wheezing. It occurs when air enters the pleural space, causing lung collapse.

A. Notify the blood bank of the suspected transfusion reaction. B. Maintain IV access with normal saline infusion. C. Facilitate the transfer of the patient to the critical care unit. D. Recheck identification labels and numbers.

Correct Answer is B

Explanation

Choice A reason: Notifying the blood bank of the suspected transfusion reaction is important, but maintaining the IV access with normal saline infusion takes priority to ensure that the patient remains stable and to prevent any further complications.

Choice B reason: Maintaining IV access with normal saline infusion is the first priority. This action helps to keep the vein open, provide fluids, and flush out any remaining blood product from the IV line, reducing the risk of further reaction.

Choice C reason: Facilitating the transfer of the patient to the critical care unit may be necessary if the patient's condition worsens, but it is not the immediate first step.

Choice D reason: Rechecking identification labels and numbers is important to confirm the correct blood product was given, but it comes after ensuring the patient’s stability by maintaining IV access with saline.

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The nurse is caring for a patient with diabetic ketoacidosis (DKA). What clinical manifestations will the nurse anticipate the patient to present? (Select All That Apply)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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