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: A client receiving 30% oxygen via a non-rebreather face mask may be at risk for oxygen toxicity, but it does not necessarily indicate a higher risk of aspiration.

Choice B: A client with a nasogastric tube to low, intermittent suction may be at risk for aspiration if the tube is not functioning properly, but it does not represent the greatest risk compared to the other options.

Choice C: A client experiencing dysphagia who is prescribed a full liquid diet is at the greatest risk for aspiration. Dysphagia can lead to difficulty swallowing, increasing the risk of food or liquids entering the airway during swallowing.

Choice D: A client who has sensory aphasia and is receiving a clear liquid diet may have difficulty understanding or communicating about their dietary needs, but this does not necessarily indicate a higher risk of aspiration compared to a client with dysphagia.

A. Pureed regular diet. B. High protein soft diet. C. Mechanical soft diet. D. Low residue diet.

Correct Answer is C

Explanation

Choice A: A pureed regular diet may not provide enough nutritional support for a client who has lost 25% of their body weight and is experiencing stomatitis. This diet may not have the necessary nutrients to address the client's nutritional needs.

Choice B: A high protein soft diet may be appropriate for some clients, but it may still be challenging for a client with stomatitis to consume. Additionally, the focus should also be on providing adequate overall nutrition, not just protein.

Choice C: A mechanical soft diet is often recommended for clients with stomatitis because it provides foods that are easier to chew and swallow while still offering a variety of nutrients. It is a suitable option for clients who have difficulty eating due to oral mucositis (stomatitis).

Choice D: A low residue diet may not provide sufficient nutrients for a client who has lost 25% of their body weight and is experiencing difficulty eating due to stomatitis. This diet may be too restrictive for their nutritional needs.

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Naxlex Comprehensive Predictor Exams

Which client is at greatest risk for aspiration?

Correct Answer is C

Explanation

A client who is receiving antineoplastic chemotherapy has lost 25% of total body weight and is having difficulty eating because of stomatitis. In planning care for this client, which diet should the nurse recommend?

Correct Answer is C

Explanation

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.)

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