A nurse is collecting data from a client who has diabetes mellitus.
Which of the following findings indicates that the client is experiencing DKA?
Confusion
Polydipsia
Rapid pulse
Clammy skin
Correct Answer : A,B,C
Choice A rationale:
Confusion can be a symptom of Diabetic Ketoacidosis (DKA). DKA is a serious complication of diabetes that occurs when your body produces high levels of blood acids called ketones. The condition develops when your body can’t produce enough insulin. Insulin normally plays a key role in helping sugar (glucose) — a major source of energy for your muscles and other tissues — enter your cells. Without enough insulin, your body begins to break down fat as fuel. This process produces a buildup of acids in the bloodstream called ketones, eventually leading to diabetic ketoacidosis if untreated.
Choice B rationale:
Polydipsia, or excessive thirst, is another common symptom of DKA. High blood sugar levels can cause increased urination, leading to dehydration and an increased feeling of thirst.
Choice C rationale:
A rapid pulse is also a symptom of DKA. This is because the body is trying to compensate for the low amount of fluid in your blood vessels due to dehydration.
Choice D rationale:
Clammy skin is not typically a symptom of DKA. It’s more commonly associated with hypoglycemia (low blood sugar), not hyperglycemia (high blood sugar) which is what occurs in DKA1.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale:
A WBC count of 16,000/mm is higher than the normal range of 5,000 to 10,000 cells/mm. This indicates that the body is fighting an infection, which is a common reason for prescribing Vancomycin. Therefore, a high WBC count could indicate a therapeutic response to the medication as it suggests that the body’s immune system is actively fighting the infection.
Choice B rationale:
A BUN level of 42 mg/dl is higher than the normal range of 7 to 20 mg/dL3456. Elevated BUN levels can indicate kidney damage or disease, which is not a desired therapeutic response to Vancomycin. Vancomycin can be nephrotoxic, and its use requires careful monitoring of kidney function. Therefore, a high BUN level does not indicate a therapeutic response to the medication. Choice C rationale:
A blood pressure reading of 95/64 is considered normal. Maintaining normal blood pressure is important for overall health and can indicate that the patient’s body is responding well to the medication. Therefore, a blood pressure reading within the normal range could indicate a therapeutic response to Vancomycin.
Choice D rationale:
A body temperature of 101.8F is considered a fever14. Fever is a common response to infection and can indicate that the body is fighting off an infection, which is a common reason for prescribing Vancomycin. Therefore, a high body temperature could indicate a therapeutic response to the medication as it suggests that the body’s immune system is actively fighting the infection.
Correct Answer is C
Explanation
Choice A rationale:
Erythromycin Erythromycin is a macrolide antibiotic that is often used as an alternative to penicillin. It is generally safe for use in patients with a penicillin allergy. It works by inhibiting bacterial protein synthesis and is effective against a wide range of bacteria.
Choice B rationale:
Amphotericin B Amphotericin B is an antifungal medication, not an antibiotic. It is used to treat serious, systemic fungal infections. It has no cross-reactivity with penicillin, so it would not be a concern for a patient with a penicillin allergy.
Choice C rationale:
Amoxicillin-clavulanate Amoxicillin-clavulanate is a type of penicillin antibiotic. Patients with a known penicillin allergy should avoid this medication, as they may have a cross-reactivity to it. This is why the nurse should verify this prescription with the provider.
Choice D rationale:
Gentamicin Gentamicin is an aminoglycoside antibiotic used to treat serious bacterial infections caused by gram-negative bacteria. It is not related to penicillin and would be safe for a patient with a penicillin allergy.
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