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 B

Explanation

Choice A reason:

Pain with movement of the left great toe is incorrect finding: Pain may be expected in a client with a fractured left tibia, especially if the great toe is moved. Pain is more related to the fracture and may not specifically indicate altered tissue perfusion.

Choice B reason:

Faint pedal pulse of the left leg is correct because it indicates that the blood flow to the foot is diminished. The pedal pulse is the pulse felt on the top of the foot, and its faintness could suggest reduced arterial blood flow to the foot.

Choice C reason:

Warm skin temperature distal to the pin site is incorrect: Warm skin distal to the pin site may indicate adequate blood flow and could be a normal finding. Warmth is generally associated with increased blood flow to the area.

Choice D reason:

Purulent drainage at the pin site is incorrect. Purulent drainage at the pin site could indicate an infection, but it is not directly related to altered tissue perfusion. Infection can lead to complications, but it does not necessarily indicate reduced blood flow to the extremity.

A. "When you get better you will not feel this way." B. "Are you thinking of hurting yourself?" C. "What would your family do without you?" D. "Why would you think a thing like that?"

Correct Answer is B

Explanation

The correct answer is B. The nurse should assess the client's risk for suicide by asking directly about suicidal thoughts or plans. This is a priority intervention that can help prevent harm to the client and provide appropriate referrals for further evaluation and treatment.

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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 assessing a client who is in skeletal traction for a fractured left tibia. The nurse should identify that which of the following findings indicates altered tissue perfusion of the affected extremity?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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