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 {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"None"}}
Explanation
Nursing Intervention |
Essential |
Contraindicated? |
Explanation |
Place the client in left lateral position. |
Yes |
No |
This position improves maternal and fetal blood flow and reduces the risk of hypotension. |
Decrease the IV flow rate. |
No |
Yes |
This intervention is contraindicated because the client may need fluid boluses to maintain adequate blood pressure and hydration. |
Assist with administration of ampicillin I. |
Yes |
No |
This intervention is essential because the client is positive for group B streptococcus and needs antibiotic prophylaxis to prevent neonatal infection. |
Monitor fetal heart rate. |
Yes |
No |
This intervention is essential because epidural analgesia can affect uterine contractility and fetal oxygenation. |
Request a prescription for ephedrine. |
No |
No |
This intervention is neither essential nor contraindicated. Ephedrine is a vasopressor that can be used to treat hypotension caused by epidural analgesia, but it is not routinely prescribed unless the client develops symptoms of hypotension. |
Correct Answer is C
Explanation
Choice A rationale:
"Apply fundal pressure during contractions." - Applying fundal pressure during contractions is not appropriate during the latent stage of labor. Fundal pressure is typically used during the second stage of labor (active pushing phase) to assist with fetal descent. Using it during the latent stage can be harmful.
Choice B rationale:
"Encourage the client to soak in a hot bath." - Soaking in a hot bath is generally not recommended during labor, especially without specific indications. It is essential to maintain the safety and well-being of both the mother and the baby. Encouraging the client to change positions or use comfort measures like relaxation techniques would be more appropriate.
Choice C rationale:
"Instruct the client to change positions frequently." - This is the correct answer. During the latent stage of labor, encouraging the client to change positions frequently can help promote comfort and optimize fetal positioning. Changing positions can reduce discomfort, enhance uterine contractions, and facilitate the progression of labor.
Choice D rationale:
"Tell the client to push during contractions." - Pushing during contractions is typically reserved for the second stage of labor when the cervix is fully dilated. In the latent stage, the cervix is not fully dilated, and pushing prematurely can be harmful and delay labor progress. It is essential to follow the appropriate guidelines for each stage of labor.
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