A nurse is caring for a client who was admitted with type 2 diabetes mellitus. Which of the following findings indicates hyperglycemia?

Absence of Chvostek's sign

Presence of Kussmaul respirations

Presence of diaphoresis

Absence of urinary ketones

Answer and Explanation

The Correct Answer is B

Choice A Reason:
Absence of Chvostek's sign is a wrong indication. Chvostek's sign is a twitching of facial muscles in response to tapping the facial nerve and is typically associated with low blood calcium levels (hypocalcemia). It's not directly related to hyperglycemia or high blood sugar levels. Hyperglycemia refers to high blood sugar levels, commonly associated with diabetes mellitus.
Choice B Reason:
Presence of Kussmaul respirations is a right indication. Kussmaul respirations are deep, rapid, and labored breathing patterns often seen in individuals with diabetic ketoacidosis (DKA), a severe complication of diabetes characterized by significantly high blood sugar levels and the presence of ketones in the blood and urine. This type of breathing pattern is the body's attempt to compensate for the acidic state caused by high blood sugar and the buildup of ketones.
Choice C Reason:
Presence of diaphoresis is a wrong indication. Diaphoresis refers to excessive sweating, which can occur due to various reasons such as physical activity, heat, stress, or certain medical conditions. While hyperglycemia can cause symptoms like increased thirst and frequent urination, diaphoresis alone is not a specific indicator of high blood sugar levels.
Choice D Reason:
Absence of urinary ketones is a wrong indication. The presence of urinary ketones indicates the body is breaking down fat for energy, which commonly occurs during periods of insufficient insulin (such as in hyperglycemia or diabetic ketoacidosis). However, the absence of urinary ketones doesn't necessarily rule out hyperglycemia. It's possible for hyperglycemia to be present without ketones in the urine, especially in the early stages or when the body is still managing blood sugar levels without significant ketone production.

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Free Nursing Study Resources

Correct Answer is A, B, C, D, E

Explanation

A. Cleanse the site with an antiseptic swab: Begin by cleaning the puncture site to reduce the risk of infection. B. Allow the site to dry: Let the antiseptic dry completely to prevent contamination or dilution of the blood sample. C. Pierce the puncture site quickly: Use a lancet to pierce the skin in one swift motion to minimize discomfort. D. Squeeze the site gently to obtain a blood droplet: Gently apply pressure to the site to encourage a droplet of blood to form. E. Apply blood to the test strip: Once the blood droplet forms, apply it to the test strip for analysis.

A. “I’m going to take your heart rate." B. "I need to give you diphenhydramine." C. "Are you having difficulty breathing?" D. "Do you have any allergies to medications?"

Correct Answer is C

Explanation

Choice A Reason:
“I'm going to take your heart rate”. This statement is incorrect. Monitoring vital signs like heart rate is essential in assessing a client's condition. However, in this scenario, the client's report of hives, itching, and a potential allergic reaction is more indicative of an immediate concern for anaphylaxis. While monitoring heart rate is relevant, assessing for signs of anaphylaxis, especially difficulty breathing, takes precedence due to the urgency of potential respiratory distress.
Choice B Reason:
"I need to give you diphenhydramine". This statement is incorrect, administering an antihistamine like diphenhydramine can help alleviate allergic symptoms, including itching and hives. However, confirming the severity of the reaction and ensuring there are no life-threatening symptoms such as breathing difficulties is the immediate priority before administering any medication.
Choice C Reason:
"Are you having difficulty breathing?" This statement is correct. This question directly assesses the client's respiratory status, a crucial indicator of anaphylaxis. If the client is experiencing difficulty breathing, it indicates a severe allergic reaction that requires immediate intervention and emergency medical attention. Recognizing and addressing potential respiratory distress is of utmost importance in managing an allergic reaction to medication.
Choice D Reason:
"Do you have any allergies to medications? This statement is incorrect. Understanding the client's medical history, including allergies, is crucial. However, in this acute situation where the client is already experiencing symptoms of a potential allergic reaction shortly after receiving penicillin, addressing the current symptoms and assessing for signs of anaphylaxis is the most immediate concern.

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A nurse is caring for a client who was admitted with type 2 diabetes mellitus. Which of the following findings indicates hyperglycemia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A, B, C, D, E

Explanation

A nurse administered a dose of penicillin to a client 30 min ago. The client reports she has hives and is itching. Which of the following statements by the nurse is the highest priority?

Correct Answer is C

Explanation

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