Exhibits

For each assessment finding, click to specify if the assessment finding is consistent with diabetic ketoacidosis (DKA) or hyperglycemic-hyperosmolar state (HHS). Each finding may support more than 1 disease process.

Urine ketones

Creatinine greater than expected reference range

Blood glucose greater than expected reference range

Skin turgor

Blood pH greater than expected reference range

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A,B"},"E":{"answers":"B"}}

Urine ketones:

They are commonly present in DKA due to the breakdown of fats as an alternative energy source when insulin is insufficient. Ketones in urine are a hallmark sign of DKA.

Ketones may not be present in urine in HHS because insulin levels are sufficient to prevent excessive breakdown of fats. Therefore, urine ketones are more specific to DKA.

Creatinine greater than expected reference range

DKA: In DKA, dehydration and electrolyte imbalances can lead to acute kidney injury (AKI), resulting in elevated creatinine levels.

HHS: Elevated creatinine can also occur in HHS due to severe dehydration and reduced kidney perfusion.

Blood glucose greater than expected reference range:

DKA: Extremely high blood glucose levels (typically >250 mg/dL) are a hallmark of DKA due to insulin deficiency and the resultant inability to transport glucose into cells for energy.

HHS: Similar to DKA, HHS is characterized by extremely high blood glucose levels (often >600 mg/dL). Therefore, elevated blood glucose levels are consistent with both DKA and HHS.

Skin turgor

DKA: Decreased skin turgor is indicative of dehydration, which is common in DKA due to excessive urination (polyuria) and fluid loss.

HHS: Similarly, decreased skin turgor can also be seen in HHS due to profound dehydration caused by excessive hyperglycemia and osmotic diuresis.

Blood pH greater than expected reference range

DKA: DKA is characterized by metabolic acidosis, leading to a decreased blood pH (<7.35). Therefore, a pH greater than expected reference range would not be typical for DKA.

HHS: HHS, on the other hand, is characterized by severe hyperglycemia without significant ketoacidosis. Patients with HHS can have a normal or even elevated blood pH (>7.45) due to compensation mechanisms and absence of significant acidosis.

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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.

A. Tie knots in the ropes near the pulleys to shorten them. B. Increase the elevation of the affected extremity. C. Remove one of the weights. D. Pull the client up in bed.

Correct Answer is D

Explanation

D. The appropriate action would be to adjust the patient's position to restore the correct alignment and tension of the traction. This typically involves pulling the client up in bed to ensure that the weights hang freely and exert the necessary force for effective traction.

A It is not recommended to tie knots in the ropes as this action could disrupt the prescribed traction force and alignment.

B. It is helpful for other aspects of care but does not correct the traction issue caused by the weights resting on the floor.

C. This is not the correct action because it would decrease rather than increase the traction force, which is necessary for fracture alignment and healing.

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Exhibits For each assessment finding, click to specify if the assessment finding is consistent with diabetic ketoacidosis (DKA) or hyperglycemic-hyperosmolar state (HHS). Each finding may support more than 1 disease process.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Complete the following sentence by using the lists of options. The nurse should administer a total dropdown sodium chloride in the first hour, dropdown each subsequent hour.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

First Hour Administration

Subsequent Hour Administration

A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes that the weights are resting on the floor. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A charge nurse receives a call from the house supervisor requesting room assignments for four new clients. Based on the admission diagnoses, which of the following clients requires a private room?

A nurse is caring for a client immediately following a lumbar puncture. Which of the following actions should the nurse take?

Exhibits The nurse is reviewing the client's medical record. Which of the following findings indicates the client's condition has improved? Select all that apply.

A nurse is assessing a client who sustained major full-thickness burns to their lower legs 12 hr ago. Which of the following findings should the nurse expect?

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take first?

A nurse is teaching a client who has asthma about how to use a metered-dose inhaler with a spacer. Which of the following information should the nurse include in the teaching?

A nurse is providing teaching about client rights to a client who has a brain tumor. Which of the following client statements indicates an understanding of the teaching?

Exhibits Which of the following 3 provider prescriptions does the nurse anticipate?

Exhibits

For each assessment finding, click to specify if the assessment finding is consistent with diabetic ketoacidosis (DKA) or hyperglycemic-hyperosmolar state (HHS). Each finding may support more than 1 disease process.