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.

Answer and Explanation

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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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.

A. Administering a potassium-sparing diuretic. B. Administering sodium polystyrene sulfonate. C. Initiating an IV potassium infusion. D. Encouraging the client to eat bananas.

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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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?

Correct Answer is D

Explanation

A nurse is reviewing a client's laboratory values and discovers the client has a serum potassium of 6.2 mEq/L. Which of the following interventions should the nurse anticipate?

Correct Answer is B

Explanation

A patient has a serum phosphate level of 2.0 mg/dL. Which treatments should the nurse expect to be prescribed for this patient? Select all that apply.

The nurse is reviewing the health problems for a group of assigned patients. Which patient does the nurse recognize as being at increased risk for developing metabolic alkalosis?

A nurse is reviewing the laboratory results for four clients. The nurse should recognize which of the following clients has a manifestation of hypoparathyroidism?

A nurse is reviewing the laboratory results of a client who takes furosemide. Which of the following results should the nurse identify as the priority finding?

A patient's blood gases show a pH of 7.53 and bicarbonate level of 36 mEq/L. The nurse realizes that the patient is demonstrating which acid-base disorder?

A nurse is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the nurse expect?

The nurse is admitting a patient who was diagnosed with acute renal failure. Which electrolyte should the nurse expect to be most affected with this disorder?

The patient is prescribed to receive intravenous potassium chloride (KCL). Which actions should the nurse take when administering this medication? Select all that apply.