A nurse is caring for a client diagnosed with diabetic ketoacidosis. Which of the following manifestations should the nurse expect?
Blood glucose level below 40 mg/dL
Acetone odor to breath
Malignant hypertension
Cheyne-Stokes breathing
The Correct Answer is B
A. Blood glucose level below 40 mg/dL is not typical in diabetic ketoacidosis. DKA is characterized by hyperglycemia, and blood glucose levels are usually significantly elevated.
B. Acetone odor to breath is a classic sign of diabetic ketoacidosis. The presence of ketones, including acetone, can result in a fruity or sweet odor to the breath. This is often referred to as "ketone breath."
C. Malignant hypertension is not a typical manifestation of diabetic ketoacidosis. DKA is more commonly associated with dehydration, electrolyte imbalances, and metabolic acidosis.
D. Cheyne-Stokes breathing is not a characteristic respiratory pattern seen in diabetic ketoacidosis. Respiratory changes in DKA are more likely to involve rapid and deep breathing (Kussmaul respirations) as the body attempts to compensate for metabolic acidosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. COPD (Chronic Obstructive Pulmonary Disease) is not directly associated with acute pancreatitis. The common risk factors for acute pancreatitis include gallstones, alcohol use, and certain medications.
B. Hypolipidemia (low blood lipid levels) is not a typical factor associated with acute pancreatitis. Elevated levels of lipids in the blood (hyperlipidemia) can be a risk factor, but hypolipidemia is not commonly linked to pancreatitis.
C. Diabetes mellitus, while not a direct cause of acute pancreatitis, can be associated with an increased risk. Uncontrolled diabetes may contribute to the development of pancreatitis, but it is not a primary risk factor.
D. Gallstones are a significant risk factor for acute pancreatitis. Gallstones can obstruct the pancreatic duct, leading to inflammation and damage to the pancreas. This obstruction is one of the common causes of acute pancreatitis.
Correct Answer is D
Explanation
A. Applying a cold pack to the client's upper arm is not the first action. The priority is to assess and address the cause of the edema. Cold packs may be used for comfort, but they do not address the underlying issue.
B. Removing the PICC line is not the first action. Before considering removal, it is essential to assess the extent and cause of the edema. Removing the line without proper evaluation could lead to premature discontinuation of necessary treatment.
C. Notifying the provider who inserted the PICC line is important, but it is not the first action. The nurse needs to assess and intervene promptly. The provider should be informed after initial actions are taken.
D. Stopping the infusion and measuring the circumference of both upper arms is the first action. This helps determine the extent of the edema and whether it is related to the infusion. It is crucial to assess for complications such as infiltration or extravasation of the TPN solution.
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