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.

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 A

Explanation

Choice A: Taking a prescribed analgesic an hour prior to breastfeeding can help alleviate the client's intense cramping while breastfeeding. This approach can provide effective pain relief.

Choice B: Changing the infant's position during the next feeding may or may not address the underlying cause of the client's intense cramping. Pain relief through medication is a more direct intervention.

Choice C: Drinking water before breastfeeding is important for hydration but may not directly address the cramping issue.

Choice D: Voiding and emptying the bladder before each feeding is a routine practice but is not specifically aimed at relieving cramping during breastfeeding.

A. Encourage the UAP to demonstrate the effective use of the incentive spirometer to the client. B. Schedule time later in the morning to review the use of the incentive spirometer with the client. C. Ask the practical nurse assigned to care for the client to review the use of the spirometer with the client. D. Advise the UAP that the respiratory therapist is responsible to supervise the client's use of the spirometer.

Correct Answer is C

Explanation

A. Encouraging the UAP to demonstrate the effective use of the incentive spirometer may not be appropriate since the UAP may not have the necessary training or expertise to provide proper instruction.
B. Scheduling time later to review the use of the spirometer does not address the immediate need for the client to understand how to use it effectively and may delay important interventions for respiratory health.
C. Asking the practical nurse assigned to care for the client to review the use of the spirometer ensures that the client receives accurate and professional guidance. The practical nurse has the training to properly instruct the client on the effective use of the incentive spirometer, which is crucial for preventing complications like atelectasis.
D. Advising the UAP that the respiratory therapist is responsible for supervising the client's use of the spirometer does not empower the UAP to take action and does not address the immediate concern regarding the client’s ineffective use.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is multiparous on the postpartum unit reports intense cramping while breastfeeding. What instruction should the nurse provide to this client?

Correct Answer is A

Explanation

The unlicensed assistive personnel (UAP) who is caring for a postoperative client reports to the charge nurse that the client is not using the incentive spirometer effectively. What action should the charge nurse implement?

Correct Answer is C

Explanation

The nurse is performing a nutritional assessment on a client who is professional dancer. Which issue reported by the client should alert the nurse to perform further assessment?

A 37-year-old client diagnosed with chronic kidney disease (CKD) is being treated for renal osteodystrophy. Which nursing diagnosis is most likely to be included in this client's plan of care?

When conducting diet teaching for a client who was diagnosed with hypocalcemia, which foods should the nurse encourage the client to eat? (Select all that apply.)

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?

Which client is at greatest risk for aspiration?

The practical nurse (PN) is caring for an older client who is receiving chemotherapy for lung cancer. Which finding is the highest priority for the PN to report to the charge nurse? Reference ranges: Blood urea nitrogen (BUN): [Adult: 10 to 20 mg/dL or 3.6 to 7.1 mmol/L] Platelets:

After a successful cardioversion, a male client with a new onset of atrial fibrillation receives a prescription for an anticoagulant. What instruction should the practical nurse (PN) reinforce with the client?