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.

Hypotension

Respiratory alkalosis

Septic shock

Cardiac arrhythmias

Renal failure

Cerebral edema

Answer and Explanation

Correct Answer : A,D,E,F

A)   DKA can lead to several complications, including hypotension, which is indicated by the client's low blood pressure reading of 96/65 mm Hg.
B)   Respiratory alkalosis is less likely because DKA typically leads to metabolic acidosis, as indicated by the low pH of 7.30.
C)   DKA does not result in septic shock but it instead causes hypovolemic shock in case of severe dehydration.
D)   Cardiac arrhythmias can occur due to the electrolyte imbalances, as evidenced by the high potassium level of 5.5 mEq/L.
E)   Renal failure is another potential complication, suggested by the elevated creatinine level of 1.7 mg/dL. The client's hyperglycemia and dehydration can stress the kidneys, potentially leading to acute kidney injury or renal failure.
F)   Cerebral edema is a less common but severe complication of DKA, especially in children and adolescents, and should be considered given the client's symptoms of frequent urination and extreme thirst. It results from over-hydration of the client.

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Correct Answer is A

Explanation

A) Disposing of the top of the ampule in a sharps container is essential for safety to prevent accidental injuries from broken glass.
B) While placing a paper towel around the ampule's neck to break off the top with both hands is a good practice to prevent injury, it's not the primary action needed for safe disposal.
C) Expelling air into the ampule to aspirate air bubbles is unnecessary and could contaminate the medication.
D) Withdrawing the medication from the ampule using a needleless system is not typically done with ampules, as they are usually designed for single-use and require breaking the top off to access the medication.

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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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.

Nursing Test Bank

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Correct Answer is A

Explanation

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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.