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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: This is the correct intervention, because avoiding IM injections can prevent bleeding and hematoma formation in the client who has low platelet count and impaired clotting.

Choice B reason: This is an incorrect intervention, because obtaining a rectal temperature once per shift can cause trauma and bleeding in the rectal mucosa, which is highly vascularized and sensitive.

Choice C reason: This is an unnecessary intervention, because the client who has thrombocytopenia does not have an increased risk of infection, unless they also have neutropenia or immunosuppression. The client should be allowed to have visitors, as long as they follow the infection control precautions.

Choice D reason: This is an incorrect intervention, because encouraging daily flossing between teeth can cause gingival bleeding and ulceration in the client who has low platelet count and impaired clotting. The client should use a soft toothbrush and avoid dental floss.

A. You can share razors with your partner as long as they are disposable. B. You should clean bathroom surfaces with a bleach and water solution. C. You should increase your intake of raw fruits and vegetables. D. You can continue your hobby of gardening as long as you wear a mask.

Correct Answer is B

Explanation

Choice A reason: This is an incorrect statement, because the client should not share razors with anyone, even if they are disposable. Razors can cause cuts and bleeding, which can transmit the HIV virus and other infections. The client should use their own personal hygiene items and dispose of them safely.

Choice B reason: This is the correct statement, because the client should clean bathroom surfaces with a bleach and water solution. Bleach is a disinfectant that can kill germs and prevent the spread of infections. The client should also wash their hands frequently and avoid contact with bodily fluids.

Choice C reason: This is an incorrect statement, because the client should not increase their intake of raw fruits and vegetables. Raw fruits and vegetables can contain bacteria, parasites, or pesticides, which can cause infections and complications in the client who has a weakened immune system. The client should wash and cook their fruits and vegetables thoroughly before eating them.

Choice D reason: This is an incorrect statement, because the client should not continue their hobby of gardening, even if they wear a mask. Gardening can expose the client to soil, dust, fungi, or insects, which can cause infections and allergies in the client who has a compromised immune system. The client should avoid activities that can increase their risk of infection.

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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?

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