The nurse is caring for a patient with diabetic ketoacidosis. Which assessment finding indicates to the nurse that the patient is experiencing fluid volume deficit?

Hypotension

Bradycardia

Polyphagia

Rapid, deep respiration

Answer and Explanation

The Correct Answer is A

Choice A reason: Hypotension, or low blood pressure, is a common indicator of fluid volume deficit. When a patient is dehydrated or has a significant loss of fluids, their blood volume decreases, leading to lower blood pressure. This condition requires immediate attention and management to prevent complications such as shock or organ failure. Monitoring and correcting fluid balance is crucial in managing patients with diabetic ketoacidosis, making hypotension a significant assessment finding.

Choice B reason: Bradycardia, or slow heart rate, is not typically associated with fluid volume deficit. It is more often related to other conditions such as heart block, hypothyroidism, or use of certain medications. In the context of diabetic ketoacidosis, fluid volume deficit would not manifest primarily as bradycardia.

Choice C reason: Polyphagia, or excessive hunger, is a symptom commonly associated with diabetes mellitus but does not indicate fluid volume deficit. Polyphagia results from the body's inability to use glucose properly, leading to increased hunger. It is not directly related to the patient's hydration status or fluid volume.

Choice D reason: Rapid, deep respiration, also known as Kussmaul breathing, is a compensatory mechanism in response to metabolic acidosis, a hallmark of diabetic ketoacidosis. While it is an important clinical sign, it does not specifically indicate fluid volume deficit. Kussmaul respiration occurs due to the body's attempt to expel excess carbon dioxide and correct the acid-base imbalance.

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Correct Answer is ["C","E"]

Explanation

Choice A reason: Taking iron with dairy products to enhance absorption is incorrect. Calcium in dairy products can interfere with the absorption of iron. It is recommended to take iron supplements with water or vitamin C-rich foods to enhance absorption.

Choice B reason: Always taking iron supplements with meals is not necessary and can reduce absorption. Iron is best absorbed on an empty stomach, although taking it with food can help reduce gastrointestinal side effects. The timing should be individualized based on the patient's tolerance.

Choice C reason: Iron will cause the stools to darken in color, which is a common and harmless side effect of iron supplements. Patients should be informed about this to prevent unnecessary concern.

Choice D reason: Limiting foods high in fiber due to the risk of diarrhea is not necessary. High-fiber foods are generally beneficial for overall health and can help prevent constipation, which is a more common side effect of iron supplements.

Choice E reason: Including vitamin C-rich foods or drinks with your iron supplement is recommended. Vitamin C enhances the absorption of non-heme iron from supplements and plant-based sources, improving the efficacy of the treatment.

A. Perform weekly occult blood testing with gastric analysis test. B. Discuss nutritional management with inclusion of a high-protein, high-vitamin diet. C. Leave ostomy site open to air for an hour each day when changing the appliance. D. Instruct the patient and family how to give medications through their G-tube.

Correct Answer is B

Explanation

Choice A reason: Performing weekly occult blood testing with gastric analysis is not typically required for managing IBD at home. While monitoring for blood in the stool can be important, weekly testing and gastric analysis are more invasive and usually performed under specific medical instructions rather than as a routine home care intervention.

Choice B reason: Discussing nutritional management with the inclusion of a high-protein, high-vitamin diet is crucial for patients with IBD. These patients often experience malnutrition due to poor absorption and increased nutritional needs during flare-ups. A high-protein, high-vitamin diet can help promote healing, maintain muscle mass, and prevent deficiencies. This intervention supports overall health and recovery.

Choice C reason: Leaving the ostomy site open to air for an hour each day when changing the appliance is not recommended. Ostomy sites need to be kept clean and protected to prevent infection and skin irritation. Instead, the focus should be on proper cleaning and secure application of the ostomy appliance.

Choice D reason: Instructing the patient and family on how to give medications through their G-tube is not relevant if the patient has an ostomy. A G-tube is used for feeding and medication administration in patients with impaired oral intake, which is not indicated in this scenario. The focus should be on ostomy care and management.

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The nurse is caring for a patient with diabetic ketoacidosis. Which assessment finding indicates to the nurse that the patient is experiencing fluid volume deficit?

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