A nurse is caring for a client who has type 1 diabetes mellitus and a capillary blood glucose reading of 48 mg/dL. Which of the following findings should the nurse expect?

Kussmaul respirations

Diaphoresis

Decreased skin turgor

Ketonuria

Answer and Explanation

The Correct Answer is B

Choice A reason: This is an incorrect finding, because Kussmaul respirations are a sign of diabetic ketoacidosis (DKA), which is a complication of type 1 diabetes mellitus that occurs when the blood glucose is too high, not too low. Kussmaul respirations are deep and rapid breathing that help the body eliminate excess carbon dioxide and acid.

Choice B reason: This is the correct finding, because diaphoresis is a sign of hypoglycemia, which is a condition that occurs when the blood glucose is too low. Diaphoresis is excessive sweating that results from the activation of the sympathetic nervous system and the release of epinephrine, which stimulate the body to increase the blood glucose level.

Choice C reason: This is an incorrect finding, because decreased skin turgor is a sign of dehydration, which is a complication of type 1 diabetes mellitus that occurs when the blood glucose is too high, not too low. Decreased skin turgor is a loss of elasticity and firmness of the skin that results from the loss of fluid and electrolytes through the urine and the skin.

Choice D reason: This is an incorrect finding, because ketonuria is a sign of diabetic ketoacidosis (DKA), which is a complication of type 1 diabetes mellitus that occurs when the blood glucose is too high, not too low. Ketonuria is the presence of ketones in the urine, which are acidic substances that are produced when the body breaks down fat for energy due to the lack of insulin.

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Correct Answer is C

Explanation

Choice A reason: Irrigating the catheter with sterile water is an incorrect action, because the catheter should be irrigated with sterile normal saline (0.9% sodium chloride) to prevent hemolysis of the red blood cells.

Choice B reason: Clamping the drainage catheter during ambulation is an incorrect action, because the catheter should be kept patent and unclamped at all times to prevent obstruction and infection.

Choice C reason: Reporting viscous drainage with clots to the provider is a correct action, because it indicates that the irrigation is not effective and the client may need manual irrigation or surgical intervention.

Choice D reason: Removing the catheter if the client feels a strong urge to urinate is an incorrect action, because the catheter should be left in place until the provider orders its removal. The client may feel a sensation of bladder fullness or spasms due to the irrigation fluid, which can be relieved by medication or adjustment of the flow rate.

A. Reinforce teaching with the client about proper instillation of antibiotic eye drops. B. Apply warm compresses to the affected eye. C. Dim the lights in the client examination room. D. Inspect the eyes for drainage or redness.

Correct Answer is D

Explanation

Choice A reason: This is an important action, but not the first one. The nurse should first address the client's comfort and inflammation before teaching them how to use the eye drops.

Choice B reason:Option B (warm compresses)is a key intervention for blepharitis to improve meibomian gland function and reduce crusting. However, assessment (Option D) must precede treatment to ensure no contraindications (e.g., corneal abrasion) and tailor care appropriately.

Choice C reason: This is a helpful action, but not the first one. The nurse should first apply warm compresses to the affected eye, and then dim the lights to reduce the sensitivity and pain.

Choice D reason:Thefirst stepin the nursing process isassessment. Even with a diagnosis of blepharitis, the nurse mustinspect the eyesto evaluate the current severity, presence of drainage (e.g., purulent vs. serous), redness, or signs of secondary infection (e.g., bacterial involvement). This informs subsequent interventions.

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A nurse is caring for a client who has type 1 diabetes mellitus and a capillary blood glucose reading of 48 mg/dL. Which of the following findings should the nurse expect?

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