Nurs 235 Test 3 - Questions With Easy-to-Follow
Solutions
A client with type 1DM has DKA. Which of the following findings has the
greatest effect on fluid loss?
1. Hypotension
2. Decreased serum, potassium level.
3. Rapid., deep, respirations.
4. Warm dry skin. Right Ans -
A client with type one diabetes is admitted to the ER. Which of the following
respiratory patterns requires immediate action?
1. Deep rapid, respirations with long expirations.
2. Shallow, respirations alternating with long expirations.
3. Regular depth of respirations with frequent pauses.
4. Short expirations and inspirations. Right Ans -
A client has the following ABGs:
pH 7.52. PaO2 50. PaCO2 28. HCO3 24. The nurse determines that which of the
following is a possible cause for these findings?
1. COPD.
2. DKA with Kussmaul's respirations.
3. Myocardial infarction
4. Pulmonary embolus. Right Ans - 4.
Resp Alkolosis are the ABG's.
The PaO2 of 50 signifies acute respiratory failure. The nurse should consider a
conditions that lead to hypoxia and hyperventilation, such as pulmonary
embolus. COPD is associated with respiratory acidosis and elevated PaCO2.
DKA is w/ Metabolic Acidosis. An MI doesn't usually cx an acid-base
imbalance.
A 58-year-old homeless male is brought to the ER by the police after being
found unconscious on the street. Following examination and evaluation of
labs, a diagnosis of DKA is confirmed. Which of the following info is most
crucial to document on the Pt's chart? SATA
1. Size of peoples and reaction of peoples to light.
2. Response to verbal and painful stimuli.
3. Skin condition, and presence of any rashes., lesions, or ulcers.
, 4. Blood pressure.
5. Length of time the client has had DM
6. Hourly urine output. Right Ans - 1, 2, 3, 4, 6
DKA is a potentially life-threatening problem. Frequent assessments of Nuro
status, including the ability to respond to stimuli, b/p, urin output need to be
documented. Assessment of skin for possible injuries. The length of time with
DM is helpful, but it is not essential to document.
The nurse is teaching a client who is taking insulin about the signs of DKA,
which include:
1. Kussmaul respirations.
2. Excessive hunger.
3. Dry, flaky skin.
4. High blood pressure. Right Ans - 1. Kussmaul's Respirations
precipitating factors of DKA and HHS Right Ans - infection
lack of insulin->poor self-mgmt of disease
not taking extra insulin when sick
induced stress conditions like heart attack, CVA (stroke), trauma or surgery
new onset of type I resulting in DKA
new onset of type 2 resulting in HHS
pregnancy->metabolic strain can induce either
Meds
alcohol and cocaine->effects of alone and contribute to poor nutrition and
poor compliance of med regimen
Meds that can induce DKA & HHS Right Ans - CCB
BB->Propanolol
Thiazide diuretics->hydrochlorothiazide HCTZ
Sympathomimetics->dopamine, dobutamine, epinephrine, norepinephrine,
albuterol, & phenlephrine
Phenytoin
Glucocorticoids-> hydrocortisone, prednisone, dexamethasone
TPN
Serum labs for kidney fxn and why it's important to know for txmt of DKA and
HHS Right Ans - BUN 10-20. GFR >60. Creatinine 0.5-1.2
Important that these are within normal range in order to give aggressive
rehydration. 0.9 or 0.45 NS depending on which disease
Solutions
A client with type 1DM has DKA. Which of the following findings has the
greatest effect on fluid loss?
1. Hypotension
2. Decreased serum, potassium level.
3. Rapid., deep, respirations.
4. Warm dry skin. Right Ans -
A client with type one diabetes is admitted to the ER. Which of the following
respiratory patterns requires immediate action?
1. Deep rapid, respirations with long expirations.
2. Shallow, respirations alternating with long expirations.
3. Regular depth of respirations with frequent pauses.
4. Short expirations and inspirations. Right Ans -
A client has the following ABGs:
pH 7.52. PaO2 50. PaCO2 28. HCO3 24. The nurse determines that which of the
following is a possible cause for these findings?
1. COPD.
2. DKA with Kussmaul's respirations.
3. Myocardial infarction
4. Pulmonary embolus. Right Ans - 4.
Resp Alkolosis are the ABG's.
The PaO2 of 50 signifies acute respiratory failure. The nurse should consider a
conditions that lead to hypoxia and hyperventilation, such as pulmonary
embolus. COPD is associated with respiratory acidosis and elevated PaCO2.
DKA is w/ Metabolic Acidosis. An MI doesn't usually cx an acid-base
imbalance.
A 58-year-old homeless male is brought to the ER by the police after being
found unconscious on the street. Following examination and evaluation of
labs, a diagnosis of DKA is confirmed. Which of the following info is most
crucial to document on the Pt's chart? SATA
1. Size of peoples and reaction of peoples to light.
2. Response to verbal and painful stimuli.
3. Skin condition, and presence of any rashes., lesions, or ulcers.
, 4. Blood pressure.
5. Length of time the client has had DM
6. Hourly urine output. Right Ans - 1, 2, 3, 4, 6
DKA is a potentially life-threatening problem. Frequent assessments of Nuro
status, including the ability to respond to stimuli, b/p, urin output need to be
documented. Assessment of skin for possible injuries. The length of time with
DM is helpful, but it is not essential to document.
The nurse is teaching a client who is taking insulin about the signs of DKA,
which include:
1. Kussmaul respirations.
2. Excessive hunger.
3. Dry, flaky skin.
4. High blood pressure. Right Ans - 1. Kussmaul's Respirations
precipitating factors of DKA and HHS Right Ans - infection
lack of insulin->poor self-mgmt of disease
not taking extra insulin when sick
induced stress conditions like heart attack, CVA (stroke), trauma or surgery
new onset of type I resulting in DKA
new onset of type 2 resulting in HHS
pregnancy->metabolic strain can induce either
Meds
alcohol and cocaine->effects of alone and contribute to poor nutrition and
poor compliance of med regimen
Meds that can induce DKA & HHS Right Ans - CCB
BB->Propanolol
Thiazide diuretics->hydrochlorothiazide HCTZ
Sympathomimetics->dopamine, dobutamine, epinephrine, norepinephrine,
albuterol, & phenlephrine
Phenytoin
Glucocorticoids-> hydrocortisone, prednisone, dexamethasone
TPN
Serum labs for kidney fxn and why it's important to know for txmt of DKA and
HHS Right Ans - BUN 10-20. GFR >60. Creatinine 0.5-1.2
Important that these are within normal range in order to give aggressive
rehydration. 0.9 or 0.45 NS depending on which disease
