The nurse is caring for a client with diabetic ketoacidosis (DKA) who presents with polyuria, abdominal pain, vomiting, and flushed skin. Which of the following clinical manifestations suggests compensation for the acid?base disorder?
1. The patient exhibits a respiratory rate of 28 with deep inspirations.
2. The patient demonstrates shallow respirations and decreased excursion.
3. The patient has a urine output of 20 ml for the last hour.
4. The patient presents with vomiting.
The patient exhibits a respiratory rate of 28 with deep inspirations.
Rationale: The client responds to DKA, a type of metabolic acidosis, with increased rate and depth of breathing known as Kussmaul breathing. This compensatory mechanism causes the client to "blow off" or exhale CO2, a respiratory acid, to increase the pH in an attempt to return the client to normal acid−base status. Shallow breathing with decreased excursion will cause respiratory acidosis, worsening the situation. Clients with DKA may have dehydration and decreased renal perfusion secondary to polyuria, but this is part of the syndrome, not compensation. Vomiting is a symptom of DKA, not a compensatory mechanism.
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