The nurse observed that a client with diabetic ketoacidosis is experiencing abnormally deep, regular, and rapid respirations. How would the nurse document this observation in the medical record?
Bradypnea
Kussmaul's respirations
Cheyne-Stokes respirations
Biot's respirations
The Correct Answer is B
Choice A reason: This is incorrect because bradypnea is a term for slow breathing, usually less than 12 breaths per minute. The client is breathing rapidly, not slowly.
Choice B reason: This is correct because Kussmaul's respirations are a type of breathing pattern that is deep, regular, and rapid, usually more than 20 breaths per minute. Kussmaul's respirations are a sign of metabolic acidosis, which occurs in diabetic ketoacidosis due to the accumulation of ketones in the blood. The client is trying to exhale the excess carbon dioxide and lower the acidity of the blood.
Choice C reason: This is incorrect because Cheyne-Stokes respirations are a type of breathing pattern that is irregular, with periods of apnea (no breathing) alternating with periods of rapid breathing. Cheyne-Stokes respirations are a sign of cerebral dysfunction, such as stroke, brain injury, or coma.
Choice D reason: This is incorrect because Biot's respirations are a type of breathing pattern that is irregular, with periods of apnea (no breathing) interspersed with periods of normal breathing. Biot's respirations are a sign of brainstem damage, such as meningitis, encephalitis, or head trauma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is incorrect because 120 to 140 mEq/L is a low range for serum sodium, which indicates hyponatremia. Hyponatremia can cause confusion, lethargy, seizures, and coma.
Choice B reason: This is correct because 135 to 145 mEq/L is the normal range of serum sodium in adults. Sodium is essential for fluid balance, nerve transmission, and muscle contraction.
Choice C reason: This is incorrect because 150 to 160 mEq/L is a high range for serum sodium, which indicates hypernatremia. Hypernatremia can cause thirst, dry mouth, agitation, and convulsions.
Choice D reason: This is incorrect because 165 to 175 mEq/L is a very high range for serum sodium, which indicates severe hypernatremia. Severe hypernatremia can cause irreversible brain damage and death.
Correct Answer is A
Explanation
Choice A reason: This is correct because acidosis is a condition where the serum pH is lower than the normal range of 7.35 to 7.45. Acidosis can be caused by an excess of acids or a loss of bases in the body, which can affect the function of various organs and systems.
Choice B reason: This is incorrect because equal bicarbonate is not a condition, but a term that describes the balance between bicarbonate (HCO3-) and carbonic acid (H2CO3) in the blood. Bicarbonate is a base that buffers the acids in the blood and maintains the pH. Equal bicarbonate means that the ratio of bicarbonate to carbonic acid is 20:1, which is the normal value.
Choice C reason: This is incorrect because neutral carbonic acid is not a condition, but a term that describes the pH of carbonic acid (H2CO3) in the blood. Carbonic acid is an acid that forms when carbon dioxide (CO2) dissolves in water. Neutral carbonic acid means that the pH of carbonic acid is 7.0, which is neither acidic nor basic.
Choice D reason: This is incorrect because alkalosis is a condition where the serum pH is higher than the normal range of 7.35 to 7.45. Alkalosis can be caused by a loss of acids or an excess of bases in the body, which can affect the function of various organs and systems.
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