A nurse suspects that a client who has diabetes mellitus is experiencing hypoglycemia. Which of the following assessment findings supports this suspicion?
Kussmaul respirations
Increased urine output
Cool, clammy skin
Acetone breath
The Correct Answer is C
C. Cool, clammy skin is a common symptom of hypoglycemia. When blood sugar levels drop too low, the body's sympathetic nervous system is activated, causing sweating and cool, clammy skin as a response to the stress of low blood sugar.
A Kussmaul respirations are deep, rapid, and labored breathing patterns that occur in response to diabetic ketoacidosis (DKA), a complication of hyperglycemia rather than hypoglycemia. In hypoglycemia, the body typically responds with normal or shallow respirations.
B Increased urine output (polyuria) is more commonly associated with hyperglycemia, where the kidneys try to excrete excess glucose through urine. Hypoglycemia typically does not cause increased urine output.
D. Acetone breath, which has a fruity odor, is associated with diabetic ketoacidosis (DKA), a condition caused by severe hyperglycemia and metabolic acidosis. It is not a typical finding in hypoglycemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A Pertussis is highly contagious and spread through respiratory droplets. Wearing a surgical mask when providing care to the client helps prevent the spread of the bacteria to others in the healthcare setting. This is a standard precaution to minimize transmission of respiratory infections.
B. A Mantoux test, or tuberculin skin test, is used to detect tuberculosis (TB) infection, not pertussis. It is not relevant to the diagnosis or management of pertussis. The focus should be on clinical assessment and appropriate treatment for pertussis.
C Pertussis does not typically require isolation in a negative pressure airflow room. Standard precautions, including wearing a surgical mask, are generally sufficient to prevent transmission. Negative pressure rooms are typically reserved for airborne infections like tuberculosis or measles.
D. Pertussis is caused by a bacterial infection (Bordetella pertussis), not a virus. Antiviral therapy is not effective against bacterial infections such as pertussis. Family members and close contacts of the client should receive prophylactic antibiotics to prevent spread of the infection, not antiviral therapy.
Correct Answer is B
Explanation
B. Slowing the infusion rate of 0.9% sodium chloride and contacting the provider are appropriate initial actions to manage the client's dyspnea and hypertension, which are likely due to fluid overload from the IV infusion.
A Corticosteroids are not typically indicated for dyspnea and hypertension related to IV fluid administration with 0.9% sodium chloride.
C Changing the type of IV fluid to lactated Ringer's solution may be considered in some cases to address fluid balance issues. However, this decision should be made in consultation with the healthcare provider based on the client's specific clinical condition and fluid status.
D. Lowering the head of the bed to semi-Fowler's position can help improve respiratory function and reduce dyspnea. However, this action alone does not address the underlying cause of the client's symptoms.
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