What clinical manifestation(s) should the nurse expect in a client with uncontrolled diabetes mellitus and ketoacidosis? (SELECT ALL THAT APPLY)

mental status = lethargic, oriented X 3 but unsure of reason for presenting for care

arterial blood gas pH 7.47/ pCO2-40/HCO3-33/ pa02 = 95

arterial blood gas pH=7.31/pCO2-34/HCO3-17/pa02=98

heart rate=52, regular

respiratory rate = 31, deep

Answer and Explanation

Correct Answer : A,C,E

A.   Lethargy can occur in DKA due to the effects of hyperglycemia, acidosis, and dehydration. Even if the client is oriented, confusion about the reason for care suggests an altered mental state, which can be common in DKA.
B.   This ABG indicates alkalosis (pH > 7.45), which is not typical for DKA. In DKA, we would expect a lower pH (acidosis). This set of values does not align with the expected clinical picture of DKA.
C.   This ABG shows a pH of 7.31, indicating acidosis. The low HCO3 (17) supports metabolic acidosis, which is characteristic of DKA. This finding is consistent with the expected laboratory results in a patient experiencing DKA.
D.   A heart rate of 52 (bradycardia) is not a common finding in DKA. In fact, tachycardia (elevated heart rate) is typically observed due to dehydration and compensatory mechanisms. Bradycardia would not be expected in this context.
E.   A respiratory rate of 31, particularly if deep (known as Kussmaul respirations), is a classic sign of metabolic acidosis, including DKA. Kussmaul respirations are the body’s attempt to compensate for acidosis by increasing carbon dioxide elimination.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["12.5"]

Explanation

1 kilogram equals 2.2 pounds.

110 lbs, which is equivalent to 50 kg (110 lbs / 2.2).

The prescribed dose is 2 mg/kg/day, so the total daily dose is 100 mg (2 mg/kg * 50 kg). This total daily dose is divided into four doses, which means each dose is 25 mg (100 mg / 4).

The medication is supplied as 10 mg/5 mL, so for a 25 mg dose, the nurse will administer 12.5 mL (25 mg * (5 mL / 10 mg)). Therefore, the nurse will administer 12.5 mL per dose.

A. administer the PRN antianxiety medication. B. auscultate the client's breath sounds. C. elevate the head of the bed. D. prepare for mechanical ventilation.

Correct Answer is C

Explanation

A. While anxiety can exacerbate feelings of breathlessness, treating anxiety does not address the
underlying issue of respiratory distress. It is important to first stabilize the client’s respiratory condition
before managing anxiety.
B. Auscultating breath sounds can provide valuable information regarding the client’s respiratory status. However, in an emergency situation, immediate interventions to stabilize the client should take precedence over assessments, especially since the vital signs indicate significant distress.

C. Elevating the head of the bed can help improve respiratory effort by allowing better lung expansion and reducing the work of breathing. Given the client’s low oxygen saturation and signs of respiratory distress, this intervention can provide immediate relief and improve oxygenation.
D. While this may be necessary if the client's condition worsens or does not improve, it is not the first action to take. Preparing for mechanical ventilation is a more advanced intervention and should only occur after initial stabilization efforts have been made.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

What clinical manifestation(s) should the nurse expect in a client with uncontrolled diabetes mellitus and ketoacidosis? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Your patient is prescribed Solu-Medrol 2 mg/kg/day in four divided doses. The medication is supplied as 10 mg/5 mL. The patient weighs 110 lbs. How many mL's will the nurse administer per dose?

Correct Answer is ["12.5"]

Explanation

Correct Answer is C

Explanation

A client with an above the knee amputation asks the nurse why the stump needs to be wrapped with an elastic bandage. The nurse explains that it:

A client on glipizide, a sulfonylurea, reports to the nurse feeling anxious, sweaty & has a headache. The nurse's initial action is to:

The nurse is caring for a client with a diagnosis of chronic peripheral arterial disease. Which statement by the client warrants immediate intervention by the nurse?

The nurse is teaching a client who is diagnosed with peripheral arterial disease about the benefits of walking to exercise. What information should the nurse reinforce with this client?

What factors in the history of a client with schizoaffective disorders puts the client at higher risk for type 2 diabetes? (SELECT ALL THAT APPLY)

A client receives 20 units of isophane insulin suspension (NPH) insulin at 0730. The nurse teaches the client that signs of hypoglycemia are most likely to occur at what time?

A client has returned to the unit following a peripheral angiogram with a stent insertion. Four hours post procedure, the nurse can no longer palpate the dorsalis pedis pulse and the foot is cool and dusky. What should be the nurse's immediate action?