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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Bread is generally considered a suitable food choice for individuals with cholelithiasis and is not typically associated with exacerbating symptoms or gallstone formation.
Choice B: Beef broth is a liquid and does not contain the same types of fats and cholesterol that can contribute to gallstone formation. It is not typically a concern for individuals with cholelithiasis.
Choice C: Ketchup is often high in sugar and can be made with vinegar, which may exacerbate symptoms in some individuals with cholelithiasis. It is advisable to omit or limit foods high in sugar and vinegar-based condiments.
Choice D: Ice cream, while high in fat, is generally tolerated by most individuals with cholelithiasis unless they experience specific dietary sensitivities. It is not typically recommended to omit ice cream from the diet unless advised by a healthcare provider.
Correct Answer is D
Explanation
A. Serum protein is an indicator of the client’s overall nutritional status, but it is not as immediately critical to monitor as glucose levels in clients receiving TPN. Protein levels change more slowly over time and are not an acute concern.
B. While serum osmolarity is important in evaluating hydration status and electrolyte balance, it is not the primary lab to monitor during TPN administration. Glucose fluctuations are more likely to cause immediate complications.
C. Urinary ketones are typically monitored in clients with diabetic ketoacidosis (DKA), not in clients receiving TPN. Ketones are a byproduct of fat metabolism and are not a priority in TPN management.
D. Capillary glucose is the most important lab to monitor in clients on TPN because TPN solutions contain high amounts of glucose, which can lead to hyperglycemia. Monitoring glucose levels helps prevent complications such as hyperglycemia or hypoglycemia and is critical in managing the client's metabolic response to TPN.
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