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: Moist skin is not a sign of dehydration, but rather a sign of adequate hydration or sweating. Dehydration can cause dry skin, mucous membranes, and lips.
Choice B reason: Dark-colored urine is a sign of dehydration, as it indicates a high concentration of waste products and a low volume of water in the urine. Dehydration can cause the kidneys to conserve water and produce less urine.
Choice C reason: High blood pressure is not a sign of dehydration, but rather a sign of fluid overload or other factors such as stress, pain, or medication. Dehydration can cause low blood pressure, as it reduces the blood volume and the cardiac output.
Choice D reason: Distended neck veins are not a sign of dehydration, but rather a sign of fluid overload or right-sided heart failure. Dehydration can cause flat neck veins, as it reduces the venous return and the central venous pressure.
Correct Answer is A
Explanation
Choice A reason: This is correct because 3.5 to 5.0 mEq/L is the normal range of serum potassium level in adults. Potassium is an electrolyte that is important for nerve and muscle function, as well as acid-base balance.
Choice B reason: This is incorrect because 8.5 to 10.5 mg/dL is the normal range of serum calcium level in adults, not potassium. Calcium is an electrolyte that is involved in bone health, muscle contraction, and blood clotting.
Choice C reason: This is incorrect because 135 to 145 mEq/L is the normal range of serum sodium level in adults, not potassium. Sodium is an electrolyte that is essential for fluid balance, nerve transmission, and muscle contraction.
Choice D reason: This is incorrect because 1.8 to 2.6 mEq/L is the normal range of serum magnesium level in adults, not potassium. Magnesium is an electrolyte that is important for muscle and nerve function, as well as enzyme activity.
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