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 C

Explanation

Choice A: Partnering with a major pharmaceutical company to provide nebulizers at reduced cost to inner-city children is an example of a secondary prevention strategy aimed at managing asthma symptoms and exacerbations. It does not address primary prevention, which focuses on preventing the development of the condition in the first place.

Choice B: Offering free asthma screening to children at a health fair is a secondary prevention strategy aimed at early detection and management of existing asthma cases. It does not address primary prevention.

Choice C: Informing the city council of the need to strengthen the city's air pollution ordinances is a primary prevention strategy. It aims to address environmental factors (such as air pollution) that can contribute to the development of asthma in children. By reducing exposure to environmental triggers, the goal is to prevent new cases of asthma from occurring.

Choice D: Referring parents of preschoolers with asthma to a support group sponsored by the American Lung Association is a secondary prevention strategy aimed at providing support and education to

A. Perform a physical assessment. B. Determine an APGAR score. C. Dry the infant under a warming unit. D. Allow the mother to touch the infant.

Correct Answer is D

Explanation

Choice A: Performing a physical assessment of the newborn is important but should not be the first action when the infant is handed to the nurse during a cesarean delivery.

Choice B: Determining an APGAR score is important for assessing the newborn's overall condition, but allowing the mother to touch the infant should be the first action.

Choice C: Drying the infant under a warming unit is an important step to maintain the infant's body temperature, but allowing the mother to touch the infant should be prioritized first.

Choice D: Allowing the mother to touch the infant immediately after delivery is a crucial bonding and comforting moment for both the mother and the newborn. It should be the first action taken before other assessments or interventions.

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Naxlex Comprehensive Predictor Exams

A community health nurse is concerned about the incidence of asthma among preschool aged children in a metropolitan area. Which intervention reflects a primary prevention strategy the nurse might initiate to combat this chronic illness?

Correct Answer is C

Explanation

The healthcare provider hands a newborn to the circulating nurse during a cesarean delivery. What action should the nurse implement first?

Correct Answer is D

Explanation

The nurse is helping develop a meal plan based on nutritional guidelines for a 73-year-old client being discharge to home with the client's 65- year-old spouse. Which statement best indicates an understanding of the nutritional guidelines when planning meals by the two spouses?

The nurse assesses a client's fluid intake at breakfast, which consisted of oatmeal, a cup of milk, and 12 ounces of coffee. How many mL should the nurse document in the client's record? (Enter numerical value only.)

The nurse is preparing a client for ultrasonography of the gallbladder. What should the nurse instruct the client to avoid consuming the night before the test?

The practical nurse (PN) is assessing an older client with left-sided heart failure (HF). What intervention is most important for the PN to implement?

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

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?

A client with glomerulonephritis is preparing for discharge and asks the nurse which kind of diet to follow upon returning home. Which dietary teaching should the nurse include in the discharge instructions?