The nurse reviews the entries in the medical record

Exhibits

The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client.

Rationale:

A. Tachycardia: Tachycardia is common in diabetic ketoacidosis (DKA) due to dehydration, electrolyte imbalances, and compensatory mechanisms for hypotension. The heart rate increases to maintain adequate perfusion in response to fluid loss and acidosis.

B. HCO3 in expected range: In DKA, bicarbonate (HCO3) levels are decreased due to metabolic acidosis. The body uses bicarbonate to buffer excess ketone acids, so HCO3 is typically below the normal range, not within expected limits.

C. Increased PaCO2: In DKA, PaCO2 is usually decreased due to Kussmaul respirations (deep, rapid breathing) as the body attempts to compensate for metabolic acidosis by blowing off CO2. Elevated PaCO2 would indicate hypoventilation, which is not characteristic of DKA.

D. Hyperreflexia: DKA does not typically cause hyperreflexia. Neurological changes, if present, are more likely to involve lethargy, confusion, or coma due to severe acidosis, dehydration, and electrolyte imbalances, rather than exaggerated reflexes.

Rationale for correct choices

• Neurological: Reports that dizziness and palpitations started 2 months ago: Persistent dizziness and palpitations may indicate arrhythmias, decreased cardiac output, or early cardiovascular compromise. Although the client is alert and oriented, these symptoms suggest insufficient cerebral perfusion or possible underlying cardiac pathology that requires further evaluation.

• Cardiovascular: Pedal pulses +1 bilaterally, Pedal edema +1 bilaterally, Capillary refill time 5 seconds for all extremities: Diminished pulses, mild edema, and prolonged capillary refill time indicate potential peripheral arterial insufficiency and early signs of fluid overload or heart failure. These findings suggest impaired circulation and warrant further assessment.

• Respiratory: Fatigue and dyspnea with exertion started 1 week ago: New-onset exertional dyspnea and fatigue may be early indicators of compromised cardiac or pulmonary function. Despite clear lung sounds, these symptoms suggest reduced oxygen delivery or early heart failure. Prompt evaluation is required to prevent progression and to identify reversible causes.

• Vital Signs: Heart rate 105/min, Blood pressure 164/92 mm Hg: Tachycardia and hypertension indicate increased cardiac workload and potential risk for end-organ damage. Persistent elevated BP above 140/90 mm Hg is associated with cardiovascular complications, including left ventricular hypertrophy and renal impairment. Monitoring and further evaluation of cardiac function, lifestyle factors, and medication adherence are necessary.

Rationale for incorrect choices

• Neurological: Alert and oriented to person, place, and time: Being alert and oriented reflects intact cognitive function and does not require immediate further evaluation. While neurological changes may arise secondary to cardiac issues, orientation alone is within normal limits and is not concerning. This finding does not indicate acute pathology.

• Respiratory: Lungs clear to auscultation bilaterally: Clear lung sounds suggest no active pulmonary congestion, infection, or obstruction. Although dyspnea is present, the absence of adventitious lung sounds indicates that the respiratory system is not acutely compromised. Further evaluation focuses on cardiac or systemic causes rather than pulmonary pathology.