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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C"}
Explanation
Choice A rationale:
Target conditions are not mentioned in the sentence, and there is no context to suggest their relevance to the client's situation.
Choice B rationale:
Hyperactive reflexes are not commonly associated with a urinary tract infection or the prescribed medications.
Choice C rationale:
The client with a urinary tract infection and the medications mentioned (Furosemide and Trimethoprim/sulfamethoxazole) are at an increased risk of hypokalemia (low potassium levels) due to Furosemide's diuretic effect, fluid volume deficit (dehydration) from the infection, and hypertension (high blood pressure) as a potential side effect of Trimethoprim/sulfamethoxazole.
Choice D rationale:
Urinary retention is not expected in a client with a urinary tract infection; it is more commonly associated with urinary obstruction or other urinary conditions unrelated to an infection.
Correct Answer is ["A","D"]
Explanation
The correct answer is A. Limit intake of canned soups and D. Read labels on foods before eating.
Choice A rationale:
Canned soups often contain high levels of sodium, which can contribute to exceeding the recommended daily sodium intake. Limiting these can help manage sodium levels effectively.
Choice B rationale:
Choosing diet sodas over bottled water is not advisable. Diet sodas can still contain sodium and other additives that are not beneficial for a low-sodium diet. Bottled water is a better choice as it typically contains no sodium.
Choice C rationale:
Bottled salad dressings often contain high amounts of sodium. Opting for homemade or low-sodium versions is a better strategy for maintaining a low-sodium diet.
Choice D rationale:
Reading labels on foods before eating is crucial for identifying hidden sources of sodium and making informed dietary choices. This practice helps in adhering to a low-sodium diet by avoiding foods with high sodium content.
: 3
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