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A nurse in a medical clinic is caring for a client.

Click to highlight the findings that the nurse should report to the provider. To deselect a finding, click on the finding again.

Nurses' Notes

2 weeks ago, 0940:

Client presents to clinic with reports of feeling unwell for the past few weeks. Client states, "I have a sore that won't get better on my right foot." Client removed gauze bandage to reveal open wound 3 cm x 4 cm on right foot; draining small amount of purulent drainage. Client awake and alert; chest clear to auscultation; heart tones audible with no abnormal heart tones heard. Client reports frequent urination, increased thirst, and recent 4.5 kg (10 lb) weight loss without trying. Client denies pain but reports experiencing nausea. BMI is 27.

Vital Signs

2 weeks ago, 0945:

Temperature 38.3° C (100.9°F)

Heart rate 104/min

Respiratory rate 18/min

Blood pressure 98/74 mm Hg

Oxygen saturation 97% on room air

Laboratory Results

2 weeks ago 1020:

WBC count 9,500/mm3 (5,000 to 10,000/mm3)

Blood glucose 250 mg/dL (74 to 106 mg/dL)

Triiodothyronine (T3) 200 mg/dL (70 to 205 mg/dL)

I have a sore that won't get better on my right foot."

Client removed gauze bandage to reveal open wound 3 cm x 4 cm on right foot

draining small amount of purulent drainage

frequent urination

increased thirst

recent 4.5 kg (10 lb) weight loss without trying

Temperature 38.3° C (100.9°F)

Heart rate 104/min

Blood pressure 98/74 mm Hg

Blood glucose 250 mg/dL (74 to 106 mg/dL)

Answer and Explanation

The Correct Answer is ["C","D","E","F","G","H","I","J"]

Open wound on right foot with purulent drainage: A non-healing wound with purulent drainage suggests infection, which is a major concern in clients with hyperglycemia. Poor wound healing is common in diabetes due to impaired circulation and immune function.
Frequent urination, increased thirst, and unexplained 4.5 kg (10 lb) weight loss: Classic symptoms of hyperglycemia and possible diabetes mellitus. Polyuria and polydipsia result from osmotic diuresis due to high blood glucose levels, while unexplained weight loss may indicate the body breaking down fat and muscle for energy.
Temperature 38.3° C (100.9° F): Fever indicates a possible systemic infection. In diabetic clients, infections can progress rapidly and lead to complications such as cellulitis, osteomyelitis, or sepsis.
Heart rate 104/min: Tachycardia may be a response to fever, dehydration, or underlying infection. Persistent tachycardia could indicate worsening sepsis or hemodynamic instability.
Blood pressure 98/74 mm Hg: While not critically low, this blood pressure is on the lower end and could indicate early signs of dehydration from polyuria or systemic infection.
Blood glucose 250 mg/dL: Significantly elevated blood glucose suggests poor glycemic control, increasing the risk of infection, delayed wound healing, and diabetic ketoacidosis (DKA) if it continues to rise.:

Respiratory rate 18/min: A normal respiratory rate does not indicate respiratory distress or metabolic compensation.
Oxygen saturation 97% on room air: Oxygenation is within the normal range, suggesting no immediate hypoxia.
WBC count 9,500/mm³: Within the normal range, although an infection may still be present given the fever and purulent wound drainage.
Triiodothyronine (T3) 200 mg/dL: Within normal limits, ruling out thyroid dysfunction as a cause of symptoms.
BMI 27: Slightly overweight but not directly contributing to the acute condition.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. A client who has aspiration pneumonia: Pneumonia leads to hypoventilation and carbon dioxide retention, which causes respiratory acidosis. It does not typically result in metabolic alkalosis since it affects gas exchange rather than acid-base balance at the metabolic level.

B. A client who is receiving continuous gastric suctioning: Prolonged removal of gastric secretions depletes hydrochloric acid, leading to an excess of bicarbonate in the blood and resulting in metabolic alkalosis. This is a common cause of alkalosis, along with excessive vomiting or diuretic use.

C. A client who is experiencing an opioid overdose: Opioids depress the respiratory system, reducing ventilation and causing carbon dioxide buildup, leading to respiratory acidosis. This does not cause metabolic alkalosis, as the issue originates in the lungs, not metabolism.

D. A client who has uncontrolled diabetes mellitus: Diabetic ketoacidosis results in excessive production of acidic ketone bodies, which lower blood pH and cause metabolic acidosis. The acid-base disturbance in diabetes is typically acidosis, not alkalosis.

A. Desmopressin acetate B. Spironolactone C. Furosemide D. Dopamine

Correct Answer is A

Explanation

A. Desmopressin acetate: This synthetic form of antidiuretic hormone (ADH) reduces excessive urine output by increasing water reabsorption in the kidneys. It helps restore fluid balance and prevent dehydration in diabetes insipidus. Without treatment, continued polyuria can lead to severe dehydration and electrolyte imbalances.

B. Spironolactone: This potassium-sparing diuretic promotes sodium and water excretion by blocking aldosterone receptors. It is used to treat conditions like heart failure and hyperaldosteronism but would worsen polyuria and dehydration in diabetes insipidus.

C. Furosemide: This loop diuretic inhibits sodium and chloride reabsorption in the kidneys, leading to increased urine output. Administering it to a client with diabetes insipidus would further aggravate excessive fluid loss and the risk of dehydration.

D. Dopamine: This vasopressor is used to improve cardiac output and blood pressure in conditions like shock. It does not affect ADH levels or urine concentration and would not help manage the excessive diuresis seen in diabetes insipidus.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for four clients. Which of the following clients is at risk for developing metabolic alkalosis?

Correct Answer is B

Explanation

A nurse is caring for a client who has diabetes insipidus and has had a urinary output of 3,000 mL in the past 12 hr. Which of the following medications should the nurse expect to administer to the client?

Correct Answer is A

Explanation

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