A nurse is preparing a client for discharge who was admitted for diabetic ketoacidosis. Which of the following statements should the nurse include in the discharge teaching?
"If your breath smells fruity, decrease your oral intake.".
"If your blood sugar is greater than 300 milligrams per deciliter, check your urine for ketones.".
"Drink one liter of fluids daily.".
"When nausea is present, drink chilled water.".
The Correct Answer is B
Choice A rationale:
The nurse should not include the statement, "If your breath smells fruity, decrease your oral intake.”. in the discharge teaching for diabetic ketoacidosis. Fruity breath odor is a sign of diabetic ketoacidosis (DKA) due to ketone production. Decreasing oral intake would not address the underlying problem, and the client should be encouraged to seek medical attention promptly if experiencing this symptom.
Choice B rationale:
This is the correct choice. The nurse should instruct the client to check their urine for ketones if their blood sugar is greater than 300 milligrams per deciliter. High blood sugar levels can lead to ketone production, and monitoring ketones in the urine can help assess the severity of DKA and guide appropriate interventions.
Choice C rationale:
The statement, "Drink one liter of fluids daily.”. is not appropriate for a client with diabetic ketoacidosis. Clients with DKA often have fluid imbalances, and their fluid needs should be assessed and managed by healthcare professionals based on individual factors and laboratory values.
Choice D rationale:
The statement, "When nausea is present, drink chilled water.”. is not specific to diabetic ketoacidosis and may not be appropriate for all clients. Nausea can be caused by various factors, and addressing the underlying cause is important. Drinking chilled water may not necessarily alleviate nausea.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Increasing potassium consumption is unrelated to cephalexin, an antibiotic. It is not a necessary precaution or action to take while on this medication.
Choice B rationale:
Applying lotion to the skin to relieve itching is not related to cephalexin use. Itching is not a common side effect of this antibiotic, so the client's statement indicates a misunderstanding of the teaching.
Choice C rationale:
Avoiding sun exposure is essential while taking cephalexin because it is known to cause photosensitivity reactions. Sun exposure can lead to severe skin reactions, so the client's statement indicates an understanding of the teaching.
Choice D rationale:
Keeping the medication refrigerated is not necessary for cephalexin oral suspension. It should be stored at room temperature unless specified otherwise by the manufacturer. The client's statement suggests a misunderstanding of the medication storage instructions.
Correct Answer is D
Explanation
Answer: D. The nurse refers a client who has chronic obstructive pulmonary disease for palliative care services:
Rationale:
A) The nurse files an incident report regarding a medication error:
Filing an incident report about a medication error is an important action for ensuring safety and quality improvement within the healthcare setting. However, it is primarily a procedural and administrative task rather than an act of direct advocacy for an individual client's needs or rights.
B) The nurse provides wound care to a client at the time promised to the client:
Providing wound care as promised demonstrates reliability and adherence to care plans, which is essential for trust and effective nursing practice. While this action shows respect for the client's needs and preferences, it does not specifically address the broader role of advocacy, which often involves intervening on behalf of the client's best interests in more complex situations.
C) The nurse declines to inform a client's neighbor about the client's prognosis:
Maintaining client confidentiality by not sharing private information with unauthorized individuals is a fundamental aspect of ethical nursing practice. This action protects the client's privacy but is more about upholding legal and ethical standards than actively advocating for the client's overall well-being or specific needs.
D) The nurse refers a client who has chronic obstructive pulmonary disease for palliative care services:
Referring a client with chronic obstructive pulmonary disease (COPD) to palliative care services exemplifies client advocacy. This action recognizes the client's need for comprehensive support, focusing on improving quality of life, managing symptoms, and providing holistic care. It involves proactive steps to address the client's complex health needs, ensuring they receive appropriate and compassionate care beyond standard medical treatment.
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