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 metabolic alkalosis is characterized by a high pH and a high HCO3-. The patient's pH and HCO3- are both low, indicating acidosis, not alkalosis.
Choice B reason: This is incorrect because respiratory alkalosis is characterized by a high pH and a low PaCO2. The patient's pH is low and PaCO2 is normal, indicating a metabolic problem, not a respiratory one.
Choice C reason: This is incorrect because respiratory acidosis is characterized by a low pH and a high PaCO2. The patient's pH is low, but PaCO2 is normal, indicating a metabolic problem, not a respiratory one.
Choice D reason: This is correct because metabolic acidosis is characterized by a low pH and a low HCO3-. The patient's pH and HCO3- are both low, indicating a metabolic disorder. The condition is uncompensated because the PaCO2 is normal, meaning the respiratory system is not compensating for the metabolic acidosis.
Correct Answer is B
Explanation
Choice A reason: This is incorrect because 120 to 140 mEq/L is a low range for serum sodium, which indicates hyponatremia. Hyponatremia can cause confusion, lethargy, seizures, and coma.
Choice B reason: This is correct because 135 to 145 mEq/L is the normal range of serum sodium in adults. Sodium is essential for fluid balance, nerve transmission, and muscle contraction.
Choice C reason: This is incorrect because 150 to 160 mEq/L is a high range for serum sodium, which indicates hypernatremia. Hypernatremia can cause thirst, dry mouth, agitation, and convulsions.
Choice D reason: This is incorrect because 165 to 175 mEq/L is a very high range for serum sodium, which indicates severe hypernatremia. Severe hypernatremia can cause irreversible brain damage and death.
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