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 D
Explanation
Choice A Reason:
"I will apply heat to my affected ankle to decrease swelling." Heat application is generally not recommended for acute injuries like ankle sprains. Heat can increase blood flow and potentially worsen swelling. Cold therapy (like ice) is typically advised in the early stages to reduce inflammation and swelling.
Choice B Reason:
"I can bear full weight on my affected ankle." For a grade 2 ankle sprain, bearing full weight on the affected ankle might not be advisable initially. Grade 2 sprains involve partial tearing of ligaments and usually require some period of rest or limited weight-bearing to allow healing.
Choice C Reason:
"I can dangle my affected ankle from the edge of the bed. “Dangling the affected ankle from the edge of the bed is a common recommendation to help with gentle movement and improve blood flow without putting excessive stress on the injured ankle. This activity can aid in the recovery process and is often recommended.
Choice D Reason:
"I will wrap my affected ankle with an elastic bandage. “Wrapping the affected ankle with an elastic bandage is a supportive measure recommended for managing ankle sprains. It helps provide compression, support, and stabilization to the injured area, assisting in reducing swelling and providing comfort.
Correct Answer is D
Explanation
Choice A Reason:
Preparing the sterile dressing supplies 30 min before the dressing change is correct. While it's crucial to have all supplies ready before starting the procedure, preparing them 30 minutes in advance might not align with the principles of maintaining sterility. It's generally best to prepare sterile supplies just before the procedure to minimize the risk of contamination.
Choice B Reason:
Don sterile gloves before removing the dressing is incorrect. Sterile gloves should indeed be worn during the dressing change, but they should be put on after removing the old dressing. This ensures that the clean gloves don't touch potentially contaminated surfaces during the removal of the old dressing.
Choice C Reason:
Disinfect the wound bed with alcohol before applying tape is incorrect. Using alcohol to disinfect the wound bed is not recommended as it can cause tissue irritation and delay wound healing. Sterile saline or another wound cleansing solution prescribed for wound care would be more appropriate to clean the wound bed. Additionally, applying tape directly to the wound is generally avoided to prevent further damage to the fragile tissues of a pressure ulcer.
Choice D Reason:
Offering the client pain medication before the procedure is correct. Providing pain medication before the procedure ensures the client's comfort and helps manage any discomfort or pain associated with the dressing change, particularly when dealing with a stage III pressure ulcer, which can be quite sensitive.
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