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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is B. "You will need to urinate before the procedure." The rationale for this information is that intermittent catheterization is a method of draining urine from the bladder using a thin, flexible tube called a catheter. It is used to measure residual urine, which is the amount of urine left in the bladder after voiding. Residual urine can indicate problems with bladder function, such as obstruction, infection, or nerve damage .
To measure residual urine, the client should first empty their bladder by urinating normally. Then, the nurse will insert the catheter into the urethra and advance it into the bladder.The nurse will measure the amount of urine that drains out of the catheter and record it as residual urine. The nurse will then remove the catheter and dispose of it .
Correct Answer is {"xRanges":[125.765625,155.765625],"yRanges":[492.609375,522.609375]}
Explanation
The dorsalis pedis artery pulse can be palpated lateral to the extensor hallucis longus tendon (or medially to the extensor digitorum longus tendon) on the dorsal surface of the foot, distal to the dorsal most prominence of the navicular bone which serves as a reliable landmark for palpation.
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