A nurse is caring for a client in the emergency department.

Exhibits
For each assessment finding, click to specify if the assessment finding is consistent with diabetic ketoacidosis (DKA) or hyperglycemic-hyperosmolar state (HHS). Each finding may support more than 1 disease process.
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

Answer and Explanation

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.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A) Distended jugular veins are associated with fluid overload, not dehydration.

B) Pitting, dependent edema is also associated with fluid overload, not dehydration.

C) Decreased blood pressure is a common sign of dehydration due to decreased blood volume.
D) Increased blood pressure is not typically associated with dehydration and may suggest other conditions such as hypertension or fluid overload.

A. Cover electrical outlets in the client's home with tape. B. Keep the client's bedroom dark at night. C. Hang a monthly calendar in the client's bedroom. D. Place a large-face clock in the client's bedroom.

Correct Answer is D

Explanation

A. Covering electrical outlets with tape may not be sufficient for safety and could pose a fire hazard. Safety covers designed for outlets are recommended.
B. Keeping the client's bedroom dark at night may increase confusion and disorientation. Soft lighting or nightlights are preferable.
C. While a calendar may be helpful, placing it in the client's bedroom may not be as beneficial as placing it in a common area where the client spends time during the day.Furthermore, amonthly calendar can be too complex for clients with Alzheimer’s disease, especially in the later stages. Simpler tools like a daily schedule or a weekly calendar are more effective.
D. A large-face clock can help the client orient to time and reduce confusion regarding the time of day.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration?

Correct Answer is C

Explanation

A nurse is teaching the family of a client who has Alzheimer's disease about caring for the client at home. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

The nurse is reviewing the client's medical record. Exhibits The nurse is reviewing the client's medical record. Which of the following findings indicates the client's condition has improved? Select all that apply.

A nurse is caring for a client who is postoperative following an endoscopy with moderate (conscious) sedation. Which of the following assessment findings is the nurse's priority?

A nurse is reviewing the client’s medical record Exhibits For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client. Potential Prescription: Anticipated Nonessential Contraindicated

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following nursing actions are appropriate? (Select all that apply.)

A nurse is caring for a client in the emergency department. Exhibits The nurse is caring for the client in the ED. The nurse understands that the client is at risk of developing which of the following complications? Select all that apply.

A nurse is providing discharge teaching to a client who had a bilateral orchiectomy. The nurse should instruct the client to expect which of the following symptoms?

A nurse is providing discharge teaching to a client who reports that they cannot afford their prescribed medication. Which of the following statements should the nurse make?