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:
Providing pin care when the client is 4 hours postoperative is not appropriate. The client has just undergone skeletal traction placement, and pin care is usually initiated after 24 hours to allow for initial wound healing.
Choice B rationale:
Removing the weights from the traction while repositioning the client in bed is unsafe and not recommended. The weights should remain in place to provide continuous traction and alignment for the fractured hip.
Choice C rationale:
Assessing the client's circulation every 4 hours is essential to monitor for any signs of impaired circulation, such as swelling, pallor, or decreased pulses. Early detection of circulatory compromise is critical to prevent complications like compartment syndrome.
Choice D rationale:
Requesting the client to perform ankle exercises on the affected extremity is not appropriate after skeletal traction placement. Ankle exercises could disrupt traction and hinder the healing process of the fractured hip.
Correct Answer is C
Explanation
Choice A rationale:
A 23-year-old client in skeletal traction may be at risk of pressure injuries, but being young and presumably healthier than the other options, this client may have a lower risk compared to the other choices.
Choice B rationale:
A 67-year-old client with coronary artery disease may be at risk of pressure injuries, especially if the client has limited mobility or is bedridden. However, coronary artery disease alone does not significantly increase the risk of pressure injuries.
Choice C rationale:
A 32-year-old client with a spinal cord injury is most at risk of developing a pressure injury. Spinal cord injuries often result in paralysis or limited mobility, leading to prolonged pressure on specific areas of the body, which can cause pressure ulcers.
Choice D rationale:
A 55-year-old client with emphysema may have compromised lung function, but this alone does not significantly increase the risk of pressure injuries. Pressure injuries are primarily related to immobility and pressure on specific body areas.
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