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:
Administer meperidine IM is incorrect. Reason why it's not the answer: Meperidine (Demerol) is not recommended in cases of malignant hyperthermia. It can potentially exacerbate the situation by further increasing muscle rigidity and potentially contributing to the hypermetabolic state. Meperidine can trigger additional release of calcium from the sarcoplasmic reticulum in muscles, worsening the symptoms.
Choice B Reason:
Instill a warm enema solution is incorrect. Reason why it's not the answer: Introducing warm solutions can exacerbate the client's condition by further increasing body temperature. Malignant hyperthermia is characterized by a dangerous increase in body temperature, and adding heat through an enema would only make the situation worse.
Choice C Reason:
Applying a cooling blanket is recommendable. Reason why it's the answer: A cooling blanket is a recommended intervention for managing malignant hyperthermia. Lowering the body temperature is crucial in preventing further complications associated with the high fever. Cooling blankets help dissipate heat from the body, aiding in rapidly reducing the dangerously elevated temperature associated with malignant hyperthermia.
Choice D Reason:
Ventilate client with 50% oxygen is incorrect. Reason why it's not the answer: While providing oxygen support might be necessary as part of managing the overall condition, ventilating with 50% oxygen specifically may not directly address the core issue of rapidly cooling the body during a malignant hyperthermia crisis. Ventilation may be required, but the immediate concern is to cool the body to prevent complications arising from the elevated body temperature.
Correct Answer is D
Explanation
Choice A Reason:
"I can have clear liquids up to 3 hours before the procedure." This is incorrect. Clients are usually instructed to be NPO (nothing by mouth) for a certain period before the procedure, typically 6-8 hours, to reduce the risk of aspiration.
Choice B Reason:
"I can eat as soon as the procedure is completed." This is incorrect. Clients should not eat or drink until the gag reflex returns, which can take a few hours after the procedure.
Choice C Reason:
"I will receive an injection of radioactive material prior to having the procedure.” This is incorrect. An injection of radioactive material is not part of a bronchoscopy. This might be confused with a different diagnostic procedure, such as a PET scan.
Choice D Reason:
"I might have blood-tinged sputum after the procedure." This statement indicates an understanding of the teaching. It is common for clients to have a small amount of blood-tinged sputum following a bronchoscopy due to the irritation caused by the procedure.
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