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 B
Explanation
Choice A Reason
Using a hair dryer to blow hot air into the cast is not recommended. It can cause burns, soften the cast material, or create hot spots, potentially leading to skin damage or discomfort for the client.
Choice B Reason:
Perform neurovascular checks of the affected extremity every 2 hours is correct. Performing neurovascular checks regularly is crucial to assess the circulation, sensation, and movement of the affected extremity. This monitoring helps identify any signs of compromised blood flow or nerve function, which could indicate complications such as compartment syndrome.
Choice C Reason:
Positioning the fractured arm below the level of the client's heart is not advisable. Elevating the injured limb above heart level can help reduce swelling and promote blood flow, aiding in the healing process and preventing complications like swelling-related discomfort or decreased circulation.
Choice D Reason:
Immobilizing the client's fingers using a hand splint might not be necessary with a short arm cast. Typically, a short arm cast provides immobilization of the wrist and forearm while allowing some movement and function of the fingers unless specifically directed by the healthcare provider for individual circumstances.
Correct Answer is B
Explanation
Choice A Reason:
Requesting a dosage increase if the apical heart rate is less than 60/min is not necessary. Propranolol is used to lower heart rate in conditions like atrial fibrillation, so a heart rate below 60/min might be the desired effect of the medication.
Choice B Reason:
Withholding the medication if the systolic blood pressure is less than 90 mm Hg is necessary. Propranolol is a beta-blocker that can lower blood pressure. If the systolic blood pressure drops below 90 mm Hg, withholding the medication is necessary to prevent further lowering of blood pressure, which could lead to adverse effects like dizziness, fainting, or inadequate blood perfusion to vital organs.
Choice C Reason:
Administering the medication with an antacid might interfere with the absorption of propranolol, so they shouldn't be taken together unless instructed by the healthcare provider.
Choice D Reason:
Expecting increased hair growth is not an anticipated effect of propranolol. Hair growth is not a usual side effect associated with this medication.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today