A nurse is caring for a client in the emergency department.
Assessment Findings: DKA /HHS
Skin turgor
Urine ketones
Blood pH greater than expected reference range
Blood glucose greater than expected reference range
Creatinine greater than expected reference range
The Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A,B"},"E":{"answers":"A,B"}}
A) Slight tenting of the skin indicates dehydration, which is consistent with both DKA and HHS.
B) The presence of ketones in the urine is a hallmark of DKA, as it indicates the body is using fat for energy due to a lack of insulin.
C) A pH of 7.30 is lower than the normal range, suggesting acidosis, which is characteristic of DKA.
D) A blood glucose level of 468 mg/dL is significantly higher than the normal range, which is a common finding in both DKA and HHS.
E) An elevated creatinine level indicates kidney dysfunction, which can be a result of dehydration seen in both DKA and HHS.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Changing dressings is important but not the priority over assessing cardiac status in an electrical shock injury.
B. Obtaining an ECG is the priority to assess for any cardiac dysrhythmias, which can be immediate and life-threatening consequences of electrical shock injuries.
C. Administering pain medication can be done once the client's cardiac status has been evaluated and stabilized.
D. While maintaining adequate urine output is important, assessing cardiac status takes precedence.
Correct Answer is B
Explanation
A) Generalized abdominal pain reported by a client with peritonitis indicates visceral pain.
B) Pain in the left shoulder reported by a client with pancreatitis is an example of referred pain, as it occurs at a site distant from the actual pathology.
C) Substernal chest pain reported by a client with angina indicates cardiac pain, not referred pain.
D) Incisional pain reported by a postoperative client is localized and does not indicate referred pain.
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