A nurse is collecting data from a client who develops a fruity breath odor, dry mouth, and extreme thirst. Which of the following additional data should the nurse collect?
Blood glucose using a glucometer
Pupillary reaction to light
Deep tendon reflexes
Liver function laboratory values
The Correct Answer is A
Choice A reason: This is the correct data, because blood glucose using a glucometer can help diagnose and monitor the client's condition, which is likely diabetic ketoacidosis (DKA). DKA is a serious complication of diabetes mellitus, characterized by high blood glucose, ketones in the urine, and acidosis in the blood. Fruity breath odor, dry mouth, and extreme thirst are common signs of DKA.
Choice B reason: This is an irrelevant data, because pupillary reaction to light has no relation to the client's condition, which is likely DKA. Pupillary reaction to light can help assess the client's neurological status and possible brain injury.
Choice C reason: This is an irrelevant data, because deep tendon reflexes have no relation to the client's condition, which is likely DKA. Deep tendon reflexes can help assess the client's neuromuscular function and possible spinal cord injury.
Choice D reason: This is a relevant data, but not the first one. Liver function laboratory values can help assess the client's hepatic function and possible liver damage, which can be a complication of DKA. However, blood glucose using a glucometer is more urgent and specific for the diagnosis and management of DKA.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct action, because weighing the client before and after each dialysis treatment can help monitor the fluid balance and the effectiveness of the dialysis.
Choice B reason: This is an incorrect action, because the nurse should apply sterile gloves when handling the bags of dialysate fluid to prevent infection.
Choice C reason: This is an incorrect action, because the bags of dialysate fluid should be warmed to body temperature before instillation to prevent hypothermia and abdominal cramps.
Choice D reason: This is an irrelevant action, because checking peripheral circulation of the client's arms has no relation to peritoneal dialysis, which involves the insertion of a catheter into the abdominal cavity.
Correct Answer is A
Explanation
Choice A reason: This is the correct data, because blood glucose using a glucometer can help diagnose and monitor the client's condition, which is likely diabetic ketoacidosis (DKA). DKA is a serious complication of diabetes mellitus, characterized by high blood glucose, ketones in the urine, and acidosis in the blood. Fruity breath odor, dry mouth, and extreme thirst are common signs of DKA.
Choice B reason: This is an irrelevant data, because pupillary reaction to light has no relation to the client's condition, which is likely DKA. Pupillary reaction to light can help assess the client's neurological status and possible brain injury.
Choice C reason: This is an irrelevant data, because deep tendon reflexes have no relation to the client's condition, which is likely DKA. Deep tendon reflexes can help assess the client's neuromuscular function and possible spinal cord injury.
Choice D reason: This is a relevant data, but not the first one. Liver function laboratory values can help assess the client's hepatic function and possible liver damage, which can be a complication of DKA. However, blood glucose using a glucometer is more urgent and specific for the diagnosis and management of DKA.
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