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 D
Explanation
Choice A rationale:
"I should use the cap during my menstrual cycle to prevent pregnancy." Rationale: This statement is incorrect. The cervical cap should be used only during sexual intercourse to prevent pregnancy, not during the menstrual cycle. It does not provide protection against sexually transmitted infections (STIs) and should be used in conjunction with a spermicide for effectiveness.
Choice B rationale:
"I should avoid using spermicide with the cervical cap." Rationale: This statement is incorrect. To enhance the effectiveness of the cervical cap, it should be used with a spermicide. Spermicide helps immobilize and kill sperm, providing an additional barrier against pregnancy.
Choice C rationale:
"I need to have my provider check the size of the cap every 6 months." Rationale: This statement is incorrect. While it's important for the healthcare provider to properly fit the cervical cap initially, it does not require routine sizing checks every six months. However, clients should periodically check the cap for any signs of damage or deterioration.
Choice D rationale:
"I need to keep the cap in place for at least 6 hours after intercourse." Rationale: This is the correct statement. To ensure the effectiveness of the cervical cap, it should be left in place for at least six hours after intercourse. It provides a barrier that prevents sperm from reaching the cervix. However, it should not be left in place for more than 48 hours to reduce the risk of toxic shock syndrome.
Correct Answer is B
Explanation
Choice A rationale:
Stimulate the infant to cry. Stimulating the infant to cry is an important step in newborn care, as crying helps to clear the respiratory passages and establish effective breathing. However, it should not be the first action taken, as there are more immediate priorities in newborn care.
Choice B rationale:
Clear the respiratory tract. Clearing the respiratory tract should be the first action taken when caring for a newborn following a vaginal delivery. The newborn may have mucus or amniotic fluid in the airway, which can obstruct breathing. Clearing the airway ensures that the infant can breathe effectively. This action takes precedence over other tasks.
Choice C rationale:
Dry the infant off and cover the head. Drying the infant off and covering the head is important for maintaining the infant's temperature and preventing heat loss. However, it is not the first priority when compared to clearing the respiratory tract. Establishing effective breathing is of utmost importance.
Choice D rationale:
Clamp the umbilical cord. Clamping the umbilical cord is typically done after the baby is breathing and stable. It is an important step in the immediate post-delivery care, but it should not be the first action taken. Clearing the respiratory tract and ensuring the infant can breathe take precedence.
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