The nurse admits a patient to the emergency department and recognizes the patient is in diabetic ketoacidosis (DKA) when what manifestations are assessed? (Select all that apply.)
A) Fruity breath
B) Edema
C) Dehydration
D) Agitation
E) slow and deep respirations
A, C, E
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Signs of impending dangerous complications of hyperglycemia such as DKA include the following: fruity breath as the ketones build up in the system and are excreted through the lungs; dehydration as fluid and important electrolytes are lost through the kidneys; slow and deep respirations (Kussmaul's respirations) as the body tries to rid itself of high acid levels; loss of orientation and coma rather than agitation are to be expected. Edema is not a sign of DKA.
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A nursing plan of care for a patient in diabetic ketoacidosis (DKA) includes altered tissue perfusion. Why is this an appropriate nursing diagnosis?
A) Decreased extracellular fluid volume leads to decreased tissue perfusion through anaerobic metabolism. B) Kussmaul's respirations cause panting and water loss through evaporation. C) Ketoacidosis causes respiratory acidosis D) Low blood pH shifts the oxyhemoglobin dissociation curve to the left, causing poor tissue oxygenation
The management of a local hospital has decided to close a postsurgical unit in the hospital due to the nursing shortage. Of which organizational theory is this an example?
1. Chaos theory 2. Classical theory 3. Systems theory 4. Contingency theory
An elderly patient with a history of congestive heart failure was just admitted for chest pain. The patient asks a nurse, "Why did my chest pain begin after I thought someone was trying to break into my house?" The best response by the nurse is:
1. "Response to fear increases the body's demand for oxygen, which can place additional stress on your damaged heart and cause chest pain." 2. "The parasympathetic system used all of your available adrenaline, leaving you so tired that you developed chest pain." 3. "Because the release of cortisol blocks the body's response to fear, you weren't allowed sufficient time to rest, which can cause chest pain." 4. "The decrease in oxygen use during the fight-or-flight response is most likely the reason that you developed chest pain."
Which of the following is an example of breach of duty?
a. The LPN/LVN walks off the unit during the shift. b. The LPN/LVN resigns from the position. c. The LPN/LVN delegates duties to unlicensed assistive personnel. d. The LPN/LVN does not perform duties according to the standard of care.