The nurse would assess for which clinical manifestations in a client suspected of having diabetic ketoacidosis? (Select all that apply)

Glucose level at least 600 mg/dL

Fruity, acetone smell to the breath

Absence of ketones in the urine

Polyuria and polydipsia

Rapid, deep breathing.

Answer and Explanation

Correct Answer : B,D,E

Choice A Reason:
A glucose level of at least 600 mg/dL is more indicative of hyperglycemic hyperosmolar state (HHS) rather than diabetic ketoacidosis (DKA). While both conditions involve high blood sugar levels, DKA is typically characterized by blood glucose levels that are high but not as extreme as those seen in HHS1.

Choice B Reason:
A fruity, acetone smell to the breath is a classic sign of DKA. This odor is due to the presence of ketones, particularly acetone, which is exhaled. It’s one of the key clinical manifestations that can help in the diagnosis of DKA.

Choice C Reason:
The absence of ketones in the urine would not be consistent with a diagnosis of DKA. One of the hallmarks of DKA is the presence of ketones in the urine, resulting from the breakdown of fats due to a lack of insulin.

Choice D Reason:
Polyuria (excessive urination) and polydipsia (excessive thirst) are symptoms of DKA. They occur as the body tries to eliminate excess glucose through the urine, which can lead to dehydration and the need to drink more fluids.

Choice E Reason:
Rapid, deep breathing, also known as Kussmaul respiration, is a compensatory mechanism for the acidosis seen in DKA. The body attempts to correct the acidic pH by exhaling more carbon dioxide.

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Correct Answer is C

Explanation

Choice A reason:
Administering an antiemetic is an important intervention in the PACU, especially if the patient is experiencing nausea or has a history of postoperative nausea and vomiting (PONV). However, it is not the first priority. Antiemetics work by blocking the neurotransmitters that trigger the vomiting reflex. Medications such as ondansetron or promethazine may be used.

Choice B reason:
Applying sequential compression devices is a preventive measure against deep vein thrombosis (DVT), which is a risk due to immobility after surgery. These devices help improve venous return from the lower limbs by applying intermittent pressure. While important, this intervention follows after the assessment of vital signs.

Choice C reason:
Assessing vital signs is the first and foremost priority when a patient is transferred to the PACU. Vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, provide immediate information about the patient's hemodynamic status and can indicate the need for urgent interventions. Any evidence of respiratory or circulatory compromise requires immediate attention.

Choice D reason:
Hanging the Lactated Ringers solution is part of managing the patient's fluid status postoperatively. Lactated Ringers is an isotonic solution that helps to replace lost fluids and maintain electrolyte balance. While important for patient care, it is not the initial priority upon arrival in the PACU.

A. Increase sodium intake. B. Consider a move to an area with higher humidity. C. Increase water intake. D. Decrease intake of all calcium-rich foods and beverages.

Correct Answer is C

Explanation

Choice A Reason

Increasing sodium intake is not recommended for patients who have passed a calcium oxalate stone. High sodium intake can increase calcium in the urine, which can contribute to the formation of new stones. Therefore, patients are often advised to limit their sodium intake to reduce the risk of stone recurrence.

Choice B Reason

Considering a move to an area with higher humidity is not a standard recommendation for preventing the recurrence of calcium oxalate stones. While climate can affect hydration levels, it is more important for the patient to focus on direct measures to stay hydrated, such as drinking more fluids.

Choice C Reason

Increasing water intake is a key recommendation for patients who have had calcium oxalate stones. Adequate hydration is essential to dilute the urine, which helps prevent the formation of new stones. Patients are often advised to drink enough water to produce at least 2.5 liters of urine per day.

Choice D Reason

Decreasing the intake of all calcium-rich foods and beverages is not generally recommended for patients with calcium oxalate stones. In fact, a moderate intake of dietary calcium can help reduce the risk of stone formation by binding with oxalate in the intestines, which prevents it from being absorbed into the urine. Patients should consult with a healthcare provider or dietitian to determine the appropriate amount of dietary calcium.

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The nurse would assess for which clinical manifestations in a client suspected of having diabetic ketoacidosis? (Select all that apply)

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