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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Correct Answer is C

Explanation

A) Increasing the ventilator flow rate may not address the cause of the low-pressure alarm and could potentially worsen the situation.
B) Emptying water from the ventilator tubing is not typically necessary when the low-pressure alarm sounds.
C) Evaluating the client for a cuff leak is essential because a leak in the endotracheal tube cuff can cause the low-pressure alarm to sound.
D) Suctioning the client's airway is not indicated unless there are signs of airway obstruction or secretions.

A. Obtain a board that uses colored pictures as communication. B. Request an interpreter during the initial assessment. C. Familiarize themselves with commonly used signed language. D. Ask a family member to be present during the admission.

Correct Answer is B

Explanation

A) Using a communication board with colored pictures might not effectively facilitate communication for someone who primarily uses sign language.
B) Requesting an interpreter during the initial assessment ensures effective communication between the nurse and the client.
C) Familiarizing themselves with commonly used signed language may help the nurse in the long term but may not be feasible or effective during the immediate admission process.

D) Asking a family member to be present during the admission may help but may not provide the necessary communication support for effective assessment and care.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving mechanical ventilation when the low pressure alarm sounds on the ventilator. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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