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 A
Explanation
Choice A Reason:
"I will use a skin sealant before I apply the bag." This statement is appropriate. Using a skin sealant before applying the ostomy bag helps protect the skin around the stoma, creating a barrier against irritation and potential leaks from the stool. It demonstrates the client's understanding of preventive measures to maintain skin integrity.
Choice B Reason:
"I will use moisturizing soap to clean around the stoma before applying the bag." This statement is inappropriate. While keeping the area around the stoma clean is important, using moisturizing soap might not be recommended as it can leave residue and interfere with the adhesive properties of the bag. Typically, mild soap and water are recommended for cleansing.
Choice C Reason:
"I will cut the wafer opening one-fourth of an inch larger than the stoma." This statement is incorrect. Cutting the wafer opening one-fourth of an inch larger than the stoma might result in an excessively large opening, potentially leading to leaks or irritation. The ideal size is generally recommended to be as close to the stoma size as possible without causing pressure on the stoma.
Choice D Reason:
"I will need to empty the bag every 4 to 6 hours." This statement is incorrect. While regular emptying of the ostomy bag is necessary, the frequency can vary based on individual needs and stoma output. Some individuals might need to empty it more frequently or less often, depending on their stool output and comfort level.
Correct Answer is ["A","C","D"]
Explanation
Choice A Reason:
Maintaining skin integrity over the blisters is correct. Blisters form as a protective mechanism for the skin underneath. Popping or breaking blisters increases the risk of infection as it exposes the raw skin to bacteria and other contaminants.
Choice B Reason:
Applying ice to the larger blisters is incorrect.
Reason: Applying ice directly to a burn, especially to blisters, can further damage the skin and exacerbate the injury. Ice can cause additional skin damage and can potentially increase pain and delay healing.
Choice C Reason:
Administering ibuprofen for pain is correct. Ibuprofen is an effective over-the-counter pain reliever that can help manage the discomfort caused by a minor burn. It also has anti-inflammatory properties that can reduce swelling associated with burns.
Choice D Reason:
Running cool water over the affected area is correct. Running cool (not cold) water over the burn helps to cool down the burned area, soothes the pain, and helps prevent further damage to the skin. It's recommended to run water over the burn for around 10-15 minutes to effectively cool the area.
Choice E Reason:
Allowing the affected area to remain open to air is incorrect. Keeping a minor burn uncovered can increase the risk of infection as it exposes the burn to external contaminants. Covering the burn with a sterile, non-stick dressing can protect it from further damage and reduce the risk of infection.
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