Nokea
A client with a diagnosis of diabetes mellitus has a blood glucose level of 644 mg/dL (36.8 mmol/L). The nurse interprets that this client is at risk of developing which type of acid-base imbalance?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises. At the same time, the cells of the body use all available glucose. The body then breaks down glycogen and fat for fuel. The by-products of fat metabolism are acidotic and can lead to the condition known as diabetic ketoacidosis. Options 2, 3, and 4 are incorrect.
You may also like to solve these questions
Which conditions place the client receiving enteral nutrition at increased risk for aspiration? Select all that apply.
- A. Sedation
- B. Coughing
- C. An artificial airway
- D. Head-elevated position
- E. Nasotracheal suctioning
- F. Decreased level of consciousness
Correct Answer: A,B,C,E,F
Rationale: A serious complication associated with enteral feedings is aspiration of formula into the tracheobronchial tree. Some common conditions that increase the risk of aspiration include sedation, coughing, an artificial airway, nasotracheal suctioning, decreased level of consciousness, and lying flat. A head-elevated position does not increase the risk of aspiration.
On assessment of a newborn being admitted to the nursery, the nurse palpates the anterior fontanel and notes that it feels soft. The nurse determines that this finding indicates which condition?
- A. Dehydration
- B. A normal finding
- C. Increased intracranial pressure
- D. Decreased intracranial pressure
Correct Answer: B
Rationale: The anterior fontanel is normally 2 to 3 cm in width, 3 to 4 cm in length, and diamond-like in shape. It can be described as soft, which is normal, or full and bulging, which could indicate increased intracranial pressure. Conversely a depressed fontanel could mean that the infant is dehydrated.
The nurse provides information to a client diagnosed with gastroesophageal reflux disease (GERD). What information should the nurse include when discussing foods that contribute to decreased lower esophageal sphincter (LES) pressure and thus worsen the condition? Select all that apply.
- A. Alcohol
- B. Fatty foods
- C. Citrus fruits
- D. Baked potatoes
- E. Caffeinated beverages
- F. Tomatoes and tomato products
Correct Answer: A,B,C,E,F
Rationale: GERD occurs as a result of the backward flow (reflux) of gastrointestinal contents into the esophagus. The most common cause of GERD is inappropriate relaxation of the LES, which allows the reflux of gastric contents into the esophagus and exposes the esophageal mucosa to gastric contents. Factors that influence the tone and contractility of the LES and lower LES pressure include alcohol; fatty foods; citrus fruits; caffeinated beverages such as coffee, tea, and cola; tomatoes and tomato products; chocolate; nicotine in cigarette smoke; calcium channel blockers; nitrates; anticholinergics; high levels of estrogen and progesterone; peppermint and spearmint; and nasogastric tube placement. Baked potatoes would not contribute to worsening the problem.
The nurse is developing a plan of care for a client who suffered a pelvic fracture following a motor vehicle crash (MVC). Which interventions should be included in the nursing care plan to prevent skin breakdown? Select all that apply.
- A. Minimize the force and friction applied to the skin.
- B. Massage vigorously over bony prominences twice daily.
- C. Perform a systematic skin inspection at least once a day.
- D. Cleanse the skin at the time of soiling and at routine intervals.
- E. Use pillows to keep the knees and other bony prominences from direct contact with one another.
- F. Use hot water and a mild cleansing agent that minimizes irritation and dryness of the skin when bathing the client.
Correct Answer: A,C,D,E
Rationale: The client in this question is at high risk for pressure injury. Interventions for prevention of pressure injuries include minimizing the force and friction applied to the skin; performing a systematic skin inspection at least once a day, giving particular attention to the bony prominences; cleansing the skin at the time of soiling and at routine intervals; avoiding the use of hot water; and using a mild cleansing agent that minimizes irritation and dryness of the skin. Pillows should be used to keep the knees and other bony prominences from direct contact with one another, because skin contact can promote breakdown. Massaging over bony prominences (especially vigorous) can be harmful to at-risk skin surfaces.
A client is admitted to the hospital with a diagnosis of right lower lobe pneumonia. The nurse auscultates the right lower lobe, expecting to note which type of breath sounds?
- A. Absent
- B. Vesicular
- C. Bronchial
- D. Bronchovesicular
Correct Answer: C
Rationale: Bronchial sounds are normally heard over the trachea. The client with pneumonia will have bronchial breath sounds over area(s) of consolidation because the consolidated tissue carries bronchial sounds to the peripheral lung fields. The client may also have crackles in the affected area resulting from fluid in the interstitium and alveoli. Absent breath sounds are not likely to occur unless a serious complication of the pneumonia occurs. Vesicular sounds are normally heard over the lesser bronchi, bronchioles, and lobes. Bronchovesicular sounds are normally heard over the main bronchi.