A nurse is assessing a client who has type 1 diabetes. Which of the following manifestations could indicate that the client is hypoglycemic?
Poor skin turgor.
Fruity breath odor.
Kussmaul respirations.
Irritability.
The Correct Answer is D
Choice A rationale:
Poor skin turgor is a sign of dehydration and is not specifically related to hypoglycemia. It is assessed by pinching the skin on the back of the hand and observing how quickly it returns to its normal position.
Choice B rationale:
Fruity breath odor is associated with diabetic ketoacidosis (DKA), a complication of uncontrolled diabetes, not hypoglycemia. It is caused by the presence of ketones in the breath due to the breakdown of fats for energy in the absence of adequate insulin.
Choice C rationale:
Kussmaul respirations are deep, rapid, and labored breathing patterns seen in diabetic ketoacidosis (DKA), not in hypoglycemia. They are the body's attempt to blow off excess carbon dioxide and acid from the blood.
Choice D rationale:
Irritability is a common manifestation of hypoglycemia. Low blood glucose levels can affect brain function, leading to mood changes, irritability, and nervousness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Administering morphine intermittent IV bolus every 2 hours is not a suitable intervention for reducing the risk of atelectasis. While pain management is important postoperatively, morphine can depress respiratory function and increase the risk of atelectasis.
Choice B rationale:
Turning the client from side to side every 4 hours is important for preventing pressure ulcers and promoting comfort, but it is not a specific intervention for reducing the risk of atelectasis.
Choice C rationale:
Providing nasotracheal suctioning for 15 to 20 seconds at a time is not a preventive measure for atelectasis. Suctioning may be necessary for airway clearance in certain situations, but it does not address the root cause of atelectasis.
Choice D rationale:
This is the correct choice. Instructing the client to hold the inhaled breath for 2 to 5 seconds with incentive spirometer use is an effective intervention to reduce the risk of atelectasis. Incentive spirometry helps to expand the lungs and improve ventilation, preventing atelectasis after surgery.
Correct Answer is D
Explanation
Choice A rationale:
Allergy to eggs is not a contraindication for taking chondroitin with glucosamine. These supplements do not contain eggs and are generally safe for individuals with egg allergies.
Choice B rationale:
Hypotension is not directly related to the use of chondroitin with glucosamine. These supplements are not known to cause significant changes in blood pressure.
Choice C rationale:
History of hypoglycemia is not a specific concern with chondroitin and glucosamine supplements. These supplements do not significantly impact blood sugar levels in people without diabetes.
Choice D rationale:
The correct choice. The nurse should instruct the client to use chondroitin with glucosamine with caution if they are on anticoagulant therapy. Chondroitin and glucosamine may have mild anticoagulant effects, and when combined with prescribed anticoagulant medications, there is a potential risk of increased bleeding or altered blood clotting times. It is essential to monitor the client's coagulation parameters closely if they decide to use these supplements.
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