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 B
Explanation
B. Hypotension suggests inadequate perfusion, which could prompt an increase in dopamine dosage to improve blood pressure and perfusion.
A A heart rate of 60/min is within the normal range for adults and may not necessarily indicate a need to increase dopamine dosage unless accompanied by signs of inadequate perfusion
C. Oxygen saturation of 95% is within the normal range and indicates adequate oxygenation. It does not directly inform the need to increase dopamine dosage
D. A respiratory rate of 14/min is within the normal range. Respiratory rate alone does not typically guide dopamine dosage adjustments unless respiratory distress or acidosis indicates poor tissue perfusion.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
The nurse should administer a total 1320ml sodium chloride in the first hour, 880ml each subsequent hour.
Rationale
First Hour Administration
Rate: 15 ml/kg/hr Client's weight: 88 kg
Calculation: 15 ml/kg/hr × 88 kg= 1320ml/hr
Therefore, in the first hour, the nurse should administer 1320 mL of 0.9% sodium chloride.
Subsequent Hour Administration
Rate: 10 ml/kg/hr Client's weight: 88 kg
Calculation: 10 ml/kg/hr × 88kg= 880mls
Therefore, each subsequent hour after the first, the nurse should administer 880 mL of 0.9% sodium chloride.
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