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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Double room with a 4-month-old who has RSV: This is the best option. RSV is highly contagious but children with the same infection may be cohorted (roomed together) to minimize transmission to other clients and conserve private rooms for uninfected or immunocompromised children.
B. Private room with negative air pressure: Negative pressure rooms are reserved for airborne infections like tuberculosis, not RSV, which is spread through contact and droplets.
C. Private room furthest from the nurses station: While a private room is acceptable, location relative to the nurses station is not a priority. Cohorting with another RSV-positive child is equally effective.
D. Double room with a 6-month-old on droplet precautions: Unless the other child also has confirmed RSV, placing them together risks spreading the virus if their infections differ. Droplet precautions alone do not confirm the same diagnosis.
Correct Answer is A,B,D,C
Explanation
Choice A: Retracting the needle into the syringe should be done before safely disposing of the syringe.
Choice B: Placing the syringe in a puncture-resistant container is the second step to ensure safe disposal of sharp objects.
Choice C: Applying an adhesive bandage over the injection site is the final step to address the bleeding and protect the site.
Choice D: Removing disposable exam gloves is the next step to prevent any contamination.
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