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 B
Explanation
Choice A rationale:
Increased peristalsis would be a positive sign and not indicative of postoperative paralytic ileus. Increased peristalsis would mean the bowel is functioning well.
Choice B rationale:
Abdominal distension is a classic sign of postoperative paralytic ileus, where the bowel's motility is reduced or absent. This condition can lead to a buildup of gas and fluids, causing the abdomen to become distended.
Choice C rationale:
Proximal high-pitched bowel sounds can be a normal finding after surgery, but they are not indicative of paralytic ileus. They may even be heard as the bowel recovers its motility.
Choice D rationale:
Passing flatus is a positive sign, as it indicates that the bowel is working and the patient is passing gas. This is not indicative of a postoperative paralytic ileus, which is characterized by the absence of bowel movement.
Correct Answer is C
Explanation
Answer: C. "Insert the entire needle into your skin to administer medication completely."
Rationale:
A) "Administer this medication into your leg muscle."
Enoxaparin should be administered subcutaneously, typically in the abdominal area, not into a muscle. Injecting it intramuscularly can lead to unpredictable absorption and increase the risk of bleeding.
B) "Expel the excess air in the syringe before you administer the medication."
This statement is incorrect. For enoxaparin, it is recommended to retain the air bubble in the syringe. The air bubble helps ensure the entire dose is delivered and minimizes leakage at the injection site.
C) "Insert the entire needle into your skin to administer medication completely."
This is an appropriate instruction as it emphasizes the need to fully insert the needle for effective subcutaneous delivery of enoxaparin. Proper technique is essential to ensure the medication is administered as intended.
D) "Take ibuprofen for fever following administration of this medication."
This recommendation is not advisable because ibuprofen, a non-steroidal anti-inflammatory drug (NSAID), can increase the risk of bleeding, especially when taken concurrently with enoxaparin. The client should consult their healthcare provider for safe alternatives for managing fever or pain.
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