A nurse is collecting data from a client who has diabetic ketoacidosis.
Which of the following findings should the nurse expect?
Elevated blood pressure.
Clammy skin.
Fruity breath odor.
Bounding pulse.
The Correct Answer is C
Choice A rationale:
Elevated blood pressure is not typically associated with diabetic ketoacidosis (DKA) In fact, individuals with DKA often experience low blood pressure due to dehydration.
Choice B rationale:
Clammy skin can occur in DKA due to dehydration and metabolic disturbances, but it is not a specific finding that differentiates DKA from other conditions.
Choice D rationale:
A bounding pulse is not a characteristic finding in DKA. Individuals with DKA may have a rapid pulse due to the stress on the body, but it is not typically described as bounding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Limiting the use of familiar objects is not recommended for clients with Alzheimer's disease. Familiar objects can provide comfort and security to these clients and help them maintain a sense of familiarity in their environment.
Choice B rationale:
Making a schedule of daily tasks is a helpful intervention for clients with Alzheimer's disease. Routine and structure can reduce frustration and anxiety in clients with cognitive impairment by providing predictability and a sense of purpose.
Choice C rationale:
Having several family members visit daily may be overwhelming for the client with Alzheimer's disease, leading to increased confusion and agitation. It is essential to balance social interaction with the client's comfort level and needs.
Choice D rationale:
Asking questions that require more than one answer can be confusing for clients with Alzheimer's disease. s should be simple and straightforward to enhance understanding and communication.
Correct Answer is A
Explanation
The correct answer is: a. The client’s date of birth.
Choice A reason: The client’s date of birth is a critical identifier in healthcare settings. It is unique to the individual and does not change, making it a reliable way to confirm a patient’s identity. This is especially important in acute care settings where accurate patient identification is crucial for safe medication administration. Using the date of birth along with another identifier, such as the patient’s name, aligns with the best practices for patient safety.
Choice B reason: While a client’s full medical diagnosis is important information for a nurse to know, it is not used as an identifier for medication administration. The diagnosis helps inform treatment decisions and care planning but does not uniquely identify a patient. Multiple patients could have the same diagnosis, which could lead to medication errors if used as an identifier.
Choice C reason: A client’s telephone number is not a standard identifier used in healthcare settings for medication administration. Telephone numbers can change and are not unique to an individual. They also do not provide immediate verification of a patient’s identity at the bedside.
Choice D reason: The room number of the client is not a primary identifier for patient identification in medication administration. Room numbers are not unique to individuals and can change if a patient is moved. It is possible for errors to occur if room numbers are used as the sole identifier, as another patient could be in that room at a different time.
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