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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Percuss each lung segment for 15 min.: Percussing each lung segment for 15 minutes is excessive and could be uncomfortable or even harmful to the child. CPT sessions are typically shorter and are rotated among different lung segments to effectively clear secretions without causing discomfort or damage.

B. Perform vibration during the client's inspirations. Vibration is usually performed during the client's expirations, not inspirations. This helps to dislodge mucus and facilitate its removal during the exhalation phase when the airways are narrowing and pushing mucus out.

C. Administer albuterol prior to CPT: Administering a bronchodilator like albuterol before CPT helps to open the airways, making it easier to clear mucus. This is a recommended practice to enhance the effectiveness of CPT and improve airway clearance.

D. Perform CPT immediately after the child eats. Performing CPT immediately after eating is not advisable because it can lead to discomfort, nausea, or vomiting. It is typically recommended to wait at least 1-2 hours after meals to perform CPT.

A. "These tests help determine the degree of damage to the heart tissues." B. "These tests will enable the provider to determine the heart structure and mobility of the heart valves." C. "Cardiac enzymes assist in diagnosing the presence of pulmonary congestion." D. "Cardiac enzymes will identify the location of the MI."

Correct Answer is A

Explanation

A. "These tests help determine the degree of damage to the heart tissues.": Cardiac enzymes, such as troponins and creatine kinase-MB (CK-MB), are released into the blood when heart muscle is damaged. Elevated levels indicate the presence and extent of myocardial injury, helping to confirm the diagnosis of an MI.

B. "These tests will enable the provider to determine the heart structure and mobility of the heart valves.": This is incorrect; cardiac enzymes do not provide information about heart structure or valve function. An echocardiogram or other imaging studies are used for structural assessment.

C. "Cardiac enzymes assist in diagnosing the presence of pulmonary congestion.": Pulmonary congestion is not directly diagnosed with cardiac enzymes. It is typically identified through clinical assessment and imaging like chest X-rays.

D. "Cardiac enzymes will identify the location of the MI.": While cardiac enzymes confirm the presence of myocardial damage, they do not specify the exact location. The location is identified using ECG and imaging techniques.

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A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse expect?

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