A patient newly diagnosed with diabetes mellitus is admitted to the emergency department with nausea, vomiting, and abdominal pain. ABG results reveal a pH of 7.2 and a bicarbonate level of 20 mEq/L. What other assessment findings should the nurse anticipate in this patient? Select all that apply.
Dysrhythmias.
Kussmaul respirations.
Weakness.
Cold, clammy skin.
Correct Answer : B,C,E
Choice A rationale:
Dysrhythmias are not a direct consequence of diabetic ketoacidosis (DKA) or the acid-base imbalance indicated by the patient's pH of 7.2 and bicarbonate level of 20 mEq/L. DKA primarily affects the respiratory system, leading to Kussmaul respirations, not dysrhythmias.
Choice B rationale:
Kussmaul respirations are an expected finding in a patient with diabetic ketoacidosis (DKA) and metabolic acidosis. These deep, rapid breaths are the body's attempt to compensate for the acidosis by eliminating excess CO2.
Choice C rationale:
Weakness is a common symptom of DKA. The hyperglycemia and acidosis result in intracellular dehydration and impaired cellular function, leading to weakness and fatigue.
Choice D rationale:
Cold, clammy skin is not typically associated with DKA. Instead, patients with DKA may have warm, dry skin due to dehydration and impaired thermoregulation.
Choice E rationale:
Tachycardia is an expected finding in a patient with DKA. The metabolic acidosis and dehydration lead to an increase in heart rate as the body attempts to maintain perfusion.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. The client who has gastroenteritis and is febrile.
Choice A rationale:
The client with end-stage renal failure scheduled for dialysis would not be at risk for fluid volume deficit because dialysis is a treatment that removes waste, salt, and extra water to prevent them from building up in the body, keeping a safe level of certain chemicals in the blood, and controlling blood pressure.
Choice B rationale:
Being NPO (nothing by mouth) since midnight for endoscopy typically involves a short period of fasting. While it could potentially contribute to a mild fluid volume deficit, it is not as significant as other causes like vomiting or diarrhea, which can lead to more substantial fluid losses.
Choice C rationale:
A client with left-sided heart failure and an elevated BNP level is more likely to experience fluid volume overload rather than a deficit. BNP is released in response to ventricular volume expansion and pressure overload, which are indicative of heart failure, not fluid volume deficit.
Choice D rationale:
The client with gastroenteritis and a fever is at risk for fluid volume deficit due to increased fluid losses from vomiting, diarrhea, and fever-induced perspiration. These symptoms align with the common risk factors for fluid volume deficit, which include vomiting, diarrhea, and sweating.
Correct Answer is B
Explanation
The correct answer is choice B) Administering sodium polystyrene sulfonate.
Choice A rationale:
Administering a potassium-sparing diuretic is not appropriate for a client with hyperkalemia (high potassium levels). Potassium-sparing diuretics would further increase potassium levels, worsening the condition.
Choice B rationale:
Sodium polystyrene sulfonate is used to treat hyperkalemia. It works by exchanging sodium ions for potassium ions in the intestines, which helps to lower serum potassium levels by excreting it through the stool.
Choice C rationale:
Initiating an IV potassium infusion would be contraindicated in this situation as it would increase the already elevated potassium levels, potentially leading to dangerous cardiac complications.
Choice D rationale:
Encouraging the client to eat bananas is not advisable because bananas are high in potassium, which would exacerbate hyperkalemia.
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