A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse expect?
Blood glucose level below 40 mg/dL
Malignant hypertension
Cheyne-Stokes breathing
Acetone odor to breath
The Correct Answer is D
A. Blood glucose level below 40 mg/dL: Diabetic ketoacidosis (DKA) is characterized by hyperglycemia, typically with blood glucose levels significantly elevated above normal, often exceeding 250 mg/dL. A glucose level below 40 mg/dL would indicate hypoglycemia, which is not a feature of DKA.
B. Malignant hypertension: Malignant hypertension is a condition characterized by extremely high blood pressure and is not directly associated with DKA. DKA primarily involves issues with glucose and acid-base balance rather than hypertension.
C. Cheyne-Stokes breathing: Cheyne-Stokes breathing is a specific pattern of periodic breathing typically seen in severe neurologic conditions or heart failure, not in DKA. DKA is associated with Kussmaul breathing, which is deep and rapid breathing as the body attempts to compensate for metabolic acidosis.
D. Acetone odor to breath: An acetone (fruity) odor to the breath is a classic sign of DKA due to the presence of ketones in the blood and urine. This occurs because the body is breaking down fatty acids for energy, leading to the production of ketones, which are then excreted through the breath and urine.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Sweat chloride test: The sweat chloride test is the gold standard for diagnosing cystic fibrosis. A high level of chloride in the sweat confirms the diagnosis, as individuals with cystic fibrosis have defective chloride channels that result in excessive chloride and sodium in their sweat.
B. A stool fat content analysis: While stool fat content analysis can indicate malabsorption issues, which are common in cystic fibrosis, it does not definitively diagnose the condition. It is more useful for evaluating pancreatic function.
C. A sputum culture: A sputum culture can identify specific respiratory infections common in cystic fibrosis patients, such as Pseudomonas aeruginosa, but it does not diagnose the underlying condition.
D. Pulmonary function tests: Pulmonary function tests can assess lung function and help monitor the progression of cystic fibrosis, but they do not confirm the diagnosis.
Correct Answer is D
Explanation
A. Anti-inflammatory: While aspirin does have anti-inflammatory properties, it is not given for this purpose in the context of preventing heart attacks. The anti-inflammatory action is more relevant in conditions like arthritis.
B. Analgesic: Aspirin is an analgesic and can relieve pain, but this is not the primary reason for its use in clients with a history of myocardial infarction.
C. Antipyretic: Aspirin has antipyretic properties, meaning it can reduce fever, but this is not the reason it is prescribed following a myocardial infarction.
D. Antiplatelet aggregate: Aspirin is used in clients with a history of myocardial infarction for its antiplatelet properties. It helps to prevent the aggregation of platelets, thereby reducing the risk of blood clots that can lead to another heart attack.
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