The nurse would assess for which clinical manifestations in a client suspected of having diabetic ketoacidosis? (Select all that apply)

Glucose level at least 600 mg/dL

Fruity, acetone smell to the breath

Absence of ketones in the urine

Polyuria and polydipsia

Rapid, deep breathing.

Answer and Explanation

Correct Answer : B,D,E

Choice A Reason:
A glucose level of at least 600 mg/dL is more indicative of hyperglycemic hyperosmolar state (HHS) rather than diabetic ketoacidosis (DKA). While both conditions involve high blood sugar levels, DKA is typically characterized by blood glucose levels that are high but not as extreme as those seen in HHS1.

Choice B Reason:
A fruity, acetone smell to the breath is a classic sign of DKA. This odor is due to the presence of ketones, particularly acetone, which is exhaled. It’s one of the key clinical manifestations that can help in the diagnosis of DKA.

Choice C Reason:
The absence of ketones in the urine would not be consistent with a diagnosis of DKA. One of the hallmarks of DKA is the presence of ketones in the urine, resulting from the breakdown of fats due to a lack of insulin.

Choice D Reason:
Polyuria (excessive urination) and polydipsia (excessive thirst) are symptoms of DKA. They occur as the body tries to eliminate excess glucose through the urine, which can lead to dehydration and the need to drink more fluids.

Choice E Reason:
Rapid, deep breathing, also known as Kussmaul respiration, is a compensatory mechanism for the acidosis seen in DKA. The body attempts to correct the acidic pH by exhaling more carbon dioxide.

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Correct Answer is C

Explanation

Choice A Reason:
A blood glucose level of 80 mg/dL before eating falls within the normal fasting blood glucose range, which is between 70 mg/dL to 110 mg/dL. Therefore, this finding is not a priority concern for a client taking prednisone.

Choice B Reason:
Gaining 5 pounds over 7 months is not typically a priority concern unless it is sudden or unexplained. Prednisone can cause fluid retention and weight gain as a common side effect, but this gradual weight change does not indicate an immediate health risk.

Choice C Reason:
Waking up with a fever is a priority finding as it may indicate an infection. Patients on prednisone are at increased risk of infections due to its immunosuppressive effects¹. Fever could also signify an exacerbation of inflammatory bowel disease or other complications.

Choice D Reason:
While insomnia is a common side effect of prednisone and can impact quality of life, it is not typically a priority over signs that could indicate infection or exacerbation of the underlying condition

A. The medication may cause the ankles to become swollen. B. Stop taking the medication immediately if fatigued. C. Check your pulse periodically while you are on this medication. D. Drink plenty of fluids while taking this medication.

Correct Answer is C

Explanation

Choice A Reason
Metoprolol, a beta-blocker, can cause fluid retention, which may lead to swelling in the ankles. However, this is not a common side effect and is not typically included as a standard warning for patients starting on metoprolol. Patients should be aware of this potential side effect but also understand that it may not occur.

Choice B Reason
Patients should not stop taking metoprolol abruptly, especially if they experience fatigue, which can be a common side effect. Abrupt cessation can lead to rebound hypertension or angina. Instead, patients should consult their healthcare provider if they experience significant fatigue that impacts their daily activities.

Choice C Reason
Checking the pulse is an important self-monitoring measure for patients on metoprolol. This medication can slow the heart rate, and patients should be instructed on how to check their pulse and what to do if it falls below a certain rate, as advised by their healthcare provider.

Choice D Reason
While staying hydrated is generally good advice, there is no specific need to drink plenty of fluids related to the use of metoprolol for angina pectoris. Patients should follow normal hydration guidelines unless otherwise directed by their healthcare provider.

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The nurse would assess for which clinical manifestations in a client suspected of having diabetic ketoacidosis? (Select all that apply)

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Correct Answer is C

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