a nurse is assessing a client who has diabetes mellitus and is experiencing dka which of the following findings should the nurse expect
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LPN Fundamentals of Nursing Quizlet

1. When assessing a client with diabetes mellitus experiencing DKA, which of the following findings should the nurse expect?

Correct answer: C

Rationale: Kussmaul respirations are a type of deep and labored breathing pattern associated with severe metabolic acidosis, commonly observed in diabetic ketoacidosis (DKA). In DKA, the body tries to compensate for the acidic environment by increasing the respiratory rate, resulting in Kussmaul respirations. This helps eliminate excess carbon dioxide and reduce the acidity of the blood. Tremors (Choice A) are not typically associated with DKA. Urine retention (Choice B) is not a common finding in DKA; in fact, clients with DKA often have polyuria due to the osmotic diuresis caused by high blood glucose levels. Bradypnea (Choice D), which is abnormally slow breathing rate, is not a characteristic finding in DKA where the respiratory rate is usually increased to compensate for metabolic acidosis.

2. A healthcare provider is preparing to administer an intramuscular injection to an adult client. Which of the following injection sites should the healthcare provider select?

Correct answer: A

Rationale: The deltoid muscle is a common site for intramuscular injections in adults due to its accessibility and muscle mass. It is located in the upper arm and provides a sufficient area for injection. The deltoid muscle is preferred for administering vaccines and other medications that require IM administration. Choice B, the dorsogluteal muscle, is not recommended for intramuscular injections due to the proximity of major nerves and blood vessels in that area, which can lead to nerve damage or injury. Choice C, the vastus lateralis muscle, is more commonly used for infants and young children, while choice D, the rectus femoris muscle, is not typically used for intramuscular injections in adults.

3. What action should the nurse take to prevent aspiration in a client receiving enteral nutrition?

Correct answer: B

Rationale: Elevating the head of the bed to 30-45 degrees during feedings is essential to prevent aspiration in clients receiving enteral nutrition. This positioning helps decrease the risk of regurgitation and aspiration by supporting proper digestion and aiding food passage through the gastrointestinal tract. Elevating the head of the bed is a standard precautionary measure recommended to reduce the chances of aspiration and should be consistently implemented during feedings to ensure client safety and optimal enteral nutrition delivery.

4. A client has a prescription for a soft diet. Which of the following foods should the nurse offer?

Correct answer: B

Rationale: When a client is on a soft diet, it is important to offer foods that are easy to chew and swallow. Mashed potatoes are a suitable choice for a soft diet as they are soft in texture and easy to digest. Fresh apples, raw carrots, and nuts are harder and may not be appropriate for a soft diet. Fresh apples and raw carrots require more chewing, and nuts are hard and crunchy, which can be difficult for someone on a soft diet to consume. Therefore, mashed potatoes are the correct option for a client on a soft diet.

5. What action should a healthcare provider take for a client with a new colostomy?

Correct answer: A

Rationale: Emptying the colostomy bag when it is half full is crucial to prevent leakage and detachment from the skin. This practice helps to maintain the integrity of the colostomy system, reducing the risk of skin irritation and odor. It is essential for client comfort and overall stoma care.

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