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An emergency department nurse assesses a client with ketoacidosis. Which clinical manifestation should the nurse correlate with this condition?
- A. Increased rate and depth of respiration.
- B. Extremity tremors followed by seizure activity.
- C. Oral temperature of 102°F (38.9°C).
- D. Severe orthostatic hypotension.
Correct Answer: A
Rationale: Kussmaul respirations (rapid, deep breathing) are a hallmark of diabetic ketoacidosis as the body attempts to compensate for metabolic acidosis by eliminating carbon dioxide. Tremors, fever, or orthostatic hypotension are not primary manifestations.
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A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement should the nurse include in this client's plan of care to delay the onset of microvascular and macrovascular complications?
- A. Maintain tight glycemic control and prevent hyperglycemia.
- B. Prevent hypoglycemia with insulin.
- C. Restrict your fluid intake to no more than 2 liters a day.
- D. Limit your intake of protein to prevent ketoacidosis.
Correct Answer: A
Rationale: Hyperglycemia is a critical factor in the pathogenesis of long-term diabetic complications. Maintaining tight glycemic control helps delay the onset of microvascular and macrovascular complications. Fluid restriction, preventing hypoglycemia, and limiting protein are not the primary strategies for this goal.
A nurse cares for a client who has type 1 diabetes mellitus. The client asks, 'Is it okay for me to have an occasional glass of wine?' How should the nurse respond?
- A. Drinking any wine or alcohol will increase your insulin requirements.
- B. Because of poor kidney function, people with diabetes should avoid alcohol.
- C. You should not drink alcohol because it will make you hungry and overeat.
- D. One glass of wine is okay with a meal and is counted as two fat exchanges.
Correct Answer: D
Rationale: Moderate alcohol, like one glass of wine with a meal, is acceptable for well-controlled diabetes and is counted as two fat exchanges. Alcohol does not directly increase insulin needs, affect kidney function in this context, or necessarily cause overeating.
A preoperative nurse assesses a client who has type 1 diabetes mellitus prior to a surgical procedure. The client's blood glucose level is 160 mg/dL. Which action should the nurse take?
- A. Document the finding in the client's chart.
- B. Administer a bolus of regular insulin IV.
- C. Call the surgeon to cancel the procedure.
- D. Draw blood gases to assess the metabolic state.
Correct Answer: A
Rationale: A blood glucose of 160 mg/dL is within the acceptable range (140"?180 mg/dL) for perioperative management in type 1 diabetes, supporting better outcomes. The nurse should document the finding and proceed. Insulin, cancellation, or blood gases are not indicated.
A nurse develops a dietary plan for a client with diabetes mellitus and new-onset microalbuminuria. Which component of the client's diet should the nurse decrease?
- A. Carbohydrates
- B. Proteins
- C. Fats
- D. Total calories
Correct Answer: B
Rationale: Restricting dietary protein to 0.8 g/kg/day is recommended for clients with microalbuminuria to slow progression to renal failure. Carbohydrates, fats, or total calories do not need specific reduction in this context.
A nurse cares for a client who has diabetes mellitus. The nurse administers 6 units of regular insulin and 10 units of NPH insulin at 0700. At which time should the nurse assess the client for potential problems related to the NPH insulin?
- A. 800
- B. 1600
- C. 2000
- D. 2300
Correct Answer: B
Rationale: NPH insulin peaks 4"?12 hours after administration (0700), so 1600 is within the peak time for potential hypoglycemia. 0800 is too early, and 2000/2300 are too late.