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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Large, bulky stools are not uncommon after a barium enema, as the barium can cause temporary changes in stool consistency and volume. This finding would not necessarily warrant immediate reporting to the healthcare provider unless there are other concerning symptoms.
Choice B reason: Three formed stools in eight hours may indicate increased bowel activity but is not an unusual finding after a barium enema. This would not typically be a cause for concern unless accompanied by other symptoms.
Choice C reason: Streaks of blood present in the stool is a concerning finding that should be reported to the healthcare provider. The presence of blood may indicate mucosal injury, inflammation, or other complications that need to be addressed promptly.
Correct Answer is A
Explanation
Choice A reason: The ABG results of pH 7.21, PaCO2 36, HCO3 14 indicate metabolic acidosis, which is common in patients with end-stage kidney disease (ESKD). In ESKD, the kidneys lose their ability to excrete acid and maintain bicarbonate levels, leading to an accumulation of acid in the blood. This condition results in a low pH (acidic), normal PaCO2 (as the respiratory system attempts to compensate), and low HCO3 (bicarbonate).
Choice B reason: The ABG results of pH 7.50, PaCO2 29, HCO3 22 indicate respiratory alkalosis, which is not typically associated with ESKD. Respiratory alkalosis occurs when there is excessive exhalation of carbon dioxide, leading to a higher pH (alkaline). This condition is more likely to be seen in situations such as hyperventilation, anxiety, or certain lung diseases.
Choice C reason: The ABG results of pH 7.47, PaCO2 45, HCO3 33 indicate metabolic alkalosis, which is not typically associated with ESKD. Metabolic alkalosis occurs when there is an excess of bicarbonate or a loss of acid. This condition can result from factors such as vomiting, diuretic use, or excessive antacid consumption. It is not a common finding in patients with ESKD.
Choice D reason: The ABG results of pH 7.31, PaCO2 48, HCO3 24 indicate respiratory acidosis, which is not typically associated with ESKD. Respiratory acidosis occurs when there is an accumulation of carbon dioxide due to impaired respiratory function. This condition is more likely to be seen in chronic obstructive pulmonary disease (COPD) or other respiratory disorders. It is not a common finding in patients with ESKD.
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