A nurse is assessing a client who has type 1 diabetes mellitus and has a blood glucose level of 550 mg/dL. Which of the following should the nurse assess the client for if diabetic ketoacidosis (DKA) is suspected?

Dizziness

Nervousness

Mental status changes

Cool, clammy skin

Answer and Explanation

The Correct Answer is C

Choice A reason: Dizziness can be a symptom of DKA due to dehydration; however, it is not as specific as mental status changes.

Choice B reason: Nervousness is not a specific symptom of DKA and can be related to high blood glucose levels rather than DKA itself.

Choice C reason: Mental status changes such as confusion or altered consciousness are significant indicators of DKA and require immediate medical atention.

Choice D reason: Cool, clammy skin is not typically associated with DKA; instead, DKA can present with dry skin and mouth due to dehydration.

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Correct Answer is C

Explanation

Choice A reason: pH 7.30 with elevated HCO3- and PaCO2 suggests compensated respiratory acidosis, not typical for chronic kidney disease.

Choice B reason: pH 7.55 with elevated HCO3- and low PaCO2 suggests metabolic alkalosis, which is not typical for chronic kidney disease.

Choice C reason: pH 7.25 with decreased HCO3- and PaCO2 suggests metabolic acidosis, which is expected in chronic kidney disease due to the accumulation of acids.

Choice D reason: pH 7.50 with low HCO3- and PaCO2 suggests compensated metabolic alkalosis, which is not typical for chronic kidney disease.

A. The client who had general anesthesia for back surgery 4 hours ago. B. The client who has a history of liver failure. C. The client who reported eating a diet high in calcium oxalate. D. The client who was treated with antibiotics for Staphylococcus aureus infection of the skin 2 weeks ago.

Correct Answer is A

Explanation

Choice A reason: General anesthesia can cause urinary retention due to its effects on the nervous system, which may temporarily impair the normal re?exes that control urination. This is particularly relevant in the immediate postoperative period.

Choice B reason: While liver failure can have many systemic effects, it is not directly associated with an increased risk of urinary retention. Urinary retention is more commonly related to factors affecting the urinary tract or nervous system.

Choice C reason: A diet high in calcium oxalate can contribute to kidney stones, but it does not directly increase the risk of urinary retention. Urinary retention typically involves an obstruction or nerve dysfunction.

Choice D reason: Antibiotic treatment for a skin infection, even one caused by Staphylococcus aureus, would not typically result in urinary retention. Urinary retention is usually related to urinary tract obstructions, medications, or nerve issues.

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A nurse is assessing a client who has type 1 diabetes mellitus and has a blood glucose level of 550 mg/dL. Which of the following should the nurse assess the client for if diabetic ketoacidosis (DKA) is suspected?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is A

Explanation

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