A nurse is collecting data from a client who has diabetic ketoacidosis. Which of the following findings should the nurse expect?

Fruity breath odor

Clammy skin

Bounding pulse

Elevated blood pressure

Answer and Explanation

The Correct Answer is A

The correct answer is A. Fruity breath odor. This is caused by the presence of acetone, a byproduct of fat metabolism, in the breath. Diabetic ketoacidosis is a condition where the body cannot use glucose as a fuel source due to insulin deficiency or resistance, and resorts to breaking down fat for energy, resulting in ketone production and acidosis. Clammy skin, bounding pulse and elevated blood pressure are signs of a hyperglycemic hyperosmolar state (HHS), another complication of diabetes that is characterized by severe dehydration and hyperglycemia without significant ketosis or acidosis.

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Correct Answer is C

Explanation

The correct answer is choice C. Clean the stoma using an inward to outward circular motion.

Choice A rationale:

Cleansing the inner cannula with isopropyl alcohol is not recommended because it can be irritating to the mucosa. Instead, the inner cannula should be cleaned with sterile saline or a prescribed solution.

Choice B rationale:

Preparing sterile supplies after removing the inner cannula is not the correct sequence. Sterile supplies should be prepared before starting the procedure to maintain sterility and efficiency.

Choice C rationale:

Cleaning the stoma using an inward to outward circular motion is correct because it helps to prevent the spread of microorganisms from the outer skin to the stoma site, reducing the risk of infection.

Choice D rationale:

Ensuring at least three finger widths of space under tracheostomy ties is incorrect. The correct practice is to ensure that only one to two finger widths can fit under the tracheostomy ties to ensure they are secure but not too tight.

A. Blood urea nitrogen B. Triiodothyronine C. Arterial blood gases D. Prothrombin time

Correct Answer is D

Explanation

Answer: D. Prothrombin time

Rationale: Prothrombin time is a measure of how long it takes the blood to clot, which is affected by warfarin, an anticoagulant medication that prevents blood clots from forming or growing larger.

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A nurse is collecting data from a client who has diabetic ketoacidosis. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

A nurse is caring for a client who has a prescription for warfarin. Which of the following laboratory tests should the nurse monitor?

Correct Answer is D

Explanation

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