A nurse is monitoring a client who has diabetes mellitus and a glucose level of 384 mg/dl. (74 to 106 mg/dL). Which of the following findings should the nurse identify as an indication of metabolic acidosis?
Positive Trousseau's sign
Dizziness upon standing
Tingling of the fingers
Increased respiratory rate
The Correct Answer is D
Choice A Reason:
Positive Trousseau's sign is incorrect. Trousseau's sign is associated more with calcium imbalances, particularly hypocalcemia, and is assessed by inflating a blood pressure cuff on the arm to induce carpal spasm. It's not a specific indicator of metabolic acidosis related to high glucose levels in diabetes mellitus.
Choice B Reason:
Dizziness upon standing is incorrect. Dizziness upon standing, also known as orthostatic hypotension, is more commonly associated with blood pressure changes upon position changes. While it can occur in various conditions, it's not a specific indicator of metabolic acidosis in this context.
Choice C Reason:
Tingling of the fingers is incorrect. Tingling sensations, known as paresthesia, can occur due to various reasons, including nerve damage related to chronic high blood sugar levels in diabetes (diabetic neuropathy). However, it's not a direct and specific indicator of metabolic acidosis caused by high glucose levels in diabetes mellitus.
Choice D Reason:
Increased respiratory rate is correct. Metabolic acidosis in a diabetic individual can trigger compensatory mechanisms, such as increased respiratory rate (Kussmaul respirations), as the body tries to eliminate excess acids through respiration to help regulate the acid-base balance. This increased respiratory rate is an attempt to blow off carbon dioxide (a potential acidic byproduct) and decrease the acidity in the blood.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Keeping both arms below the level of the client's heart doesn't specifically address the prevention of lymphedema and might not be necessary for this purpose.
Choice B Reason:
Limiting range-of-motion exercises with the affected arm could potentially contribute to stiffness and reduced function, but appropriate and gradual range-of-motion exercises are generally recommended to prevent lymphedema.
Choice C Reason:
Using the client's left arm to obtain blood samples is correct. Lymphedema can occur due to the disruption of lymphatic vessels during surgery, leading to the accumulation of lymph fluid. To reduce the risk of lymphedema, medical procedures or blood draws should typically avoid using the affected arm. In this case, after a right radical mastectomy, using the left arm for blood samples can help protect the compromised lymphatic system in the right arm.
Choice D Reason:
Obtaining blood pressure readings using the client's right arm is not directly related to preventing lymphedema. However, excessive pressure or trauma to the affected arm should generally be avoided to reduce the risk of lymphedema.
Correct Answer is B
Explanation
Choice A Reason:
Isopropyl alcohol is the appropriate cleaning agent. While alcohol can be used as a disinfectant for some purposes, it might not be as effective as bleach against bloodborne pathogens like HIV. Bleach is generally recommended for disinfection in this context.
Choice B Reason:
Bleach is recommendable. Bleach is effective in disinfecting surfaces contaminated with bloodborne pathogens, including HIV. It's recommended for cleaning and disinfecting areas contaminated with blood as it can effectively kill many pathogens, including viruses like HIV. The standard recommendation is to create a solution of bleach and water to clean surfaces contaminated with blood.
Choice C Reason:
Hydrogen peroxide is not recommendable. Hydrogen peroxide has some disinfectant properties, but bleach is more effective against bloodborne pathogens like HIV when used to clean contaminated surfaces.
Choice D Reason:
Chlorhexidine is not appropriate. Chlorhexidine is an antiseptic commonly used for skin disinfection before procedures. While it's effective for certain purposes, it's not typically recommended for disinfecting surfaces contaminated with bloodborne pathogens like HIV. Bleach is the preferred agent in such cases.
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