A nurse is reviewing the medical record of a client who has developed a UTI. Which of the following findings should the nurse expect?

Choice A rationale:
Poor skin turgor is a sign of dehydration and is not specifically related to hypoglycemia. It is assessed by pinching the skin on the back of the hand and observing how quickly it returns to its normal position.
Choice B rationale:
Fruity breath odor is associated with diabetic ketoacidosis (DKA), a complication of uncontrolled diabetes, not hypoglycemia. It is caused by the presence of ketones in the breath due to the breakdown of fats for energy in the absence of adequate insulin.
Choice C rationale:
Kussmaul respirations are deep, rapid, and labored breathing patterns seen in diabetic ketoacidosis (DKA), not in hypoglycemia. They are the body's attempt to blow off excess carbon dioxide and acid from the blood.
Choice D rationale:
Irritability is a common manifestation of hypoglycemia. Low blood glucose levels can affect brain function, leading to mood changes, irritability, and nervousness.

Choice A rationale:

The nurse should wear a protective gown when suctioning the client's airway to prevent the spread of infection. During suctioning, there is a risk of exposure to the client's respiratory secretions, which may contain infectious organisms. Wearing a gown will help protect the nurse from contact with these secretions.

Choice B rationale:

Monitoring for oral secretions every 2 hours is essential to prevent the accumulation of mucus or saliva in the client's mouth. Excessive secretions can increase the risk of aspiration, which may lead to ventilator-associated pneumonia (VAP).

Choice C rationale:

Providing oral care every 2 hours is crucial to maintain oral hygiene and reduce the growth of bacteria in the mouth. Oral bacteria can potentially enter the lungs during mechanical ventilation, contributing to the development of VAP.

Choice D rationale:

Maintaining the client in a supine position is not recommended as it can increase the risk of VAP. The supine position may cause secretions to pool in the back of the throat, making it more likely for the client to aspirate these secretions.

Choice E rationale:

Assessing the client daily for readiness for extubation is important but not directly related to decreasing the risk of VAP. Extubation refers to the removal of the endotracheal tube, which helps prevent complications associated with prolonged intubation but does not specifically address VAP prevention.