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 C
Explanation
Choice A reason: One slice of wheat bread is not the best source of potassium, as it contains only about 70 mg of potassium per serving. The recommended daily intake of potassium for adults is 4,700 mg.
Choice B reason: One wedge of cantaloupe is a good source of potassium, as it contains about 430 mg of potassium per serving. However, it is not the best source of potassium among the choices given.
Choice C reason: One banana is the best source of potassium among the choices given, as it contains about 420 mg of potassium per serving. Bananas are also rich in fiber, vitamin C, and antioxidants.
Choice D reason: One slice of cheddar cheese is not the best source of potassium, as it contains only about 28 mg of potassium per serving. Cheese is also high in sodium, fat, and calories, which can have negative effects on blood pressure and cholesterol levels.
Correct Answer is A
Explanation
Choice A reason: Renal failure can cause hyperkalemia because the kidneys are unable to excrete excess potassium from the body. This can lead to high levels of potassium in the blood, which can affect the heart and muscles.
Choice B reason: Diarrhea can cause hypokalemia, not hyperkalemia, because it can lead to loss of potassium from the gastrointestinal tract. This can result in low levels of potassium in the blood, which can also affect the heart and muscles.
Choice C reason: Blood transfusion can cause hyperkalemia if the blood is old or hemolyzed, meaning that the red blood cells have broken down and released potassium into the plasma. This can increase the potassium levels in the recipient's blood.
Choice D reason: Diaphoresis, or sweating, can cause hypokalemia, not hyperkalemia, because it can lead to loss of potassium from the skin. This can also lower the potassium levels in the blood.
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