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 D
Explanation
Choice A rationale:
A PaO2 value of 86 mm Hg is within the normal range (80-100 mm Hg) and does not indicate respiratory acidosis. PaO2 measures the partial pressure of oxygen in arterial blood.
Choice B rationale:
A pH of 7.4 is within the normal range (7.35-7.45) and does not indicate respiratory acidosis. The pH reflects the acidity or alkalinity of the blood.
Choice C rationale:
An HCO3 (bicarbonate) level of 16 mEq/L is within the normal range (22-28 mEq/L) and does not indicate respiratory acidosis. HCO3 is a measure of the metabolic component of the body's acid-base balance.
Choice D rationale:
This is the correct choice. A PaCO2 value of 58 mm Hg is elevated and indicates respiratory acidosis. PaCO2 measures the partial pressure of carbon dioxide in arterial blood, and an elevated value suggests the presence of excess carbon dioxide, leading to acidosis.
Correct Answer is C
Explanation
Choice A rationale:
Taking sitz baths can provide comfort but will not directly address the transmission of herpes simplex virus type 2 (HSV-2). It is essential to avoid sexual activity during outbreaks to prevent spreading the infection to a partner.
Choice B rationale:
Cleansing lesions with 1/2 strength peroxide may irritate the affected area and delay healing. The recommended approach is to use gentle soap and water to clean the lesions.
Choice C rationale:
"I will avoid sexual activity until my lesions are healed.”. This statement indicates an understanding of the teaching because HSV-2 is highly contagious during active outbreaks. Avoiding sexual activity during this time is essential to prevent transmitting the virus to a partner.
Choice D rationale:
"I am not contagious once I begin antiviral medication.”. This statement is incorrect as antiviral medications can help manage outbreaks but do not eliminate the risk of transmission entirely. The virus remains contagious until lesions are completely healed.
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