The nurse observed that a client with diabetic ketoacidosis is experiencing abnormally deep, regular, and rapid respirations. How would the nurse document this observation in the medical record?
Bradypnea
Kussmaul's respirations
Cheyne-Stokes respirations
Biot's respirations
The Correct Answer is B
Choice A reason: This is incorrect because bradypnea is a term for slow breathing, usually less than 12 breaths per minute. The client is breathing rapidly, not slowly.
Choice B reason: This is correct because Kussmaul's respirations are a type of breathing pattern that is deep, regular, and rapid, usually more than 20 breaths per minute. Kussmaul's respirations are a sign of metabolic acidosis, which occurs in diabetic ketoacidosis due to the accumulation of ketones in the blood. The client is trying to exhale the excess carbon dioxide and lower the acidity of the blood.
Choice C reason: This is incorrect because Cheyne-Stokes respirations are a type of breathing pattern that is irregular, with periods of apnea (no breathing) alternating with periods of rapid breathing. Cheyne-Stokes respirations are a sign of cerebral dysfunction, such as stroke, brain injury, or coma.
Choice D reason: This is incorrect because Biot's respirations are a type of breathing pattern that is irregular, with periods of apnea (no breathing) interspersed with periods of normal breathing. Biot's respirations are a sign of brainstem damage, such as meningitis, encephalitis, or head trauma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is incorrect because sodium level of 145 mEq/L is within the normal range of 135 to 145 mEq/L. Sodium is not directly affected by respiratory alkalosis, but it may be altered by fluid balance or other conditions.
Choice B reason: This is incorrect because magnesium level of 1.3 mEq/L is within the normal range of 1.3 to 2.1 mEq/L. Magnesium is not directly affected by respiratory alkalosis, but it may be altered by renal function or other conditions.
Choice C reason: This is incorrect because phosphorus level of 3.0 mg/dL is within the normal range of 2.5 to 4.5 mg/dL. Phosphorus is not directly affected by respiratory alkalosis, but it may be altered by calcium balance or other conditions.
Choice D reason: This is correct because potassium level of 3.0 mEq/L is below the normal range of 3.5 to 5.0 mEq/L. Potassium is inversely related to hydrogen ions, which are decreased in respiratory alkalosis. As hydrogen ions move out of the cells to buffer the blood, potassium ions move into the cells to maintain electrical neutrality. This causes hypokalemia, or low potassium level.
Correct Answer is B
Explanation
Choice A reason: Moist skin is not a sign of dehydration, but rather a sign of adequate hydration or sweating. Dehydration can cause dry skin, mucous membranes, and lips.
Choice B reason: Dark-colored urine is a sign of dehydration, as it indicates a high concentration of waste products and a low volume of water in the urine. Dehydration can cause the kidneys to conserve water and produce less urine.
Choice C reason: High blood pressure is not a sign of dehydration, but rather a sign of fluid overload or other factors such as stress, pain, or medication. Dehydration can cause low blood pressure, as it reduces the blood volume and the cardiac output.
Choice D reason: Distended neck veins are not a sign of dehydration, but rather a sign of fluid overload or right-sided heart failure. Dehydration can cause flat neck veins, as it reduces the venous return and the central venous pressure.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.