A client is admitted with diabetic ketoacidosis (DKA). Upon admission, the client was drowsy and nauseated with reports of a headache. An hour after admission, the practical nurse (PN) is assisting with the care of the client. Which finding is most important for the PN to report to the charge nurse?

Urine appears very dilute.

Client is not responsive.

Breath has a fruity odor.

Skin is flushed and dry.

Answer and Explanation

The Correct Answer is B

Choice A: Urine appearing very dilute may be a concern but is not the most critical finding in a client with diabetic ketoacidosis (DKA).

Choice B: The client not being responsive is the most important finding to report. It may indicate a worsening of the client's condition, possibly related to the progression of DKA or other complications.

Choice C: A fruity odor to the breath is a common symptom of DKA and may have been present upon admission. While it is important to monitor, it is not the highest priority among the choices provided.

Choice D: Flushed and dry skin can be a symptom of DKA but is not the most important finding to report if the client is unresponsive. The client's level of consciousness takes precedence.

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Correct Answer is D

Explanation

Choice A: A mechanical soft diet may still require some degree of chewing, which may be difficult for a client with no teeth. A pureed diet would be a more appropriate choice.

Choice B: A soft low-residue diet may include soft foods that require chewing, which could be challenging for a client with no teeth.

Choice C: A full liquid diet consists of liquids and foods that are in liquid form at room temperature, which may not provide adequate nutrition for the client.

Choice D: A pureed diet involves blending foods to a smooth consistency, making them suitable for clients with no teeth or difficulty chewing. It would be the most appropriate choice.

A. Thready pulse volume. B. Missing pulse. C. Pulse skips beats. D. Light pressure applied to pulse.

Correct Answer is A

Explanation

Choice A: A thready pulse is one that is weak and can be easily obliterated by light pressure.

Choice B: A missing pulse is one that cannot be felt at all.

Choice C: "Pulse skips beats" is a different phenomenon and not an accurate description of the pulse disappearing with light pressure. It is irregular and may indicate a cardiac arrhythmia.

Choice D: Documenting "light pressure applied to pulse" does not convey the specific finding that the pulse disappears with pressure, which is more clinically relevant. It is not a finding, but a method of assessing the pulse.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the admission assessment, an older male client who has no teeth tells the nurse that he cannot find his dentures at home. His dietary prescription is a regular diet. What diet request should the nurse recommend for this client?

Correct Answer is D

Explanation

The practical nurse (PN) palpates a client's radial pulse and notes that the pulse disappears when light pressure is applied. How should the PN document this finding?

Correct Answer is A

Explanation

A client expresses an interest in reducing intake of saturated fats and plans to stop eating hamburgers at lunch. Which menu item should the nurse suggest as an alternative source of protein?

When conducting diet teaching for a client who is on a gastrostomy tube feeding, which foods should the nurse encourage the client use? (Select all that apply.)

A male child is being prepared for a computed tomography (CT) scan when he begins to have a tonic clonic seizure. His mother is hysterical and is trying to hold the child down. Which action(s) should the nurse take? (Select all that apply.)

A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea (sudden aimless movements of the arms and legs). Which information should the nurse provide to the parents?

The nurse is caring for an older client with that is exhibiting signs of confusion. Which intervention should the nurse implement?

The practical nurse (PN) is charting vital signs on a hand-written flow sheet and realizes that an error has been made. What should the PN do to rectify this error?

The nurse is caring for an older adult who needs to limit sodium intake. Which food should the nurse encourage the client to avoid?

A client with a hemothorax has a chest tube in the fourth intercostal space connected to suction at 20 cm H2O pressure. Four hours after insertion, which client outcome should the nurse consider to be within normal limits for this client?