A patient has been admitted to the hospital with the diagnosis of DKA. What vital signs should a nurse anticipate that the patient will exhibit?
Temperature, 98° F; pulse, 84 beats/min; respirations, 18 breaths/min and shallow
Temperature, 99° F; pulse, 62 beats/min; respirations, 16 breaths/min and shallow
Temperature, 97.4° F; pulse, 110 beats/min; respirations, 26 breaths/min and deep
Temperature, 98.6° F; pulse, 76 beats/min; respirations, 16 breaths/min and deep
The Correct Answer is C
Rationale:
A. Normal pulse and respiratory rates do not indicate the expected tachycardia or Kussmaul respirations in DKA.
B. This option shows a slower heart rate, which is not typical of DKA where tachycardia is expected.
C. In diabetic ketoacidosis (DKA), clients typically exhibit tachycardia due to dehydration and deep, rapid Kussmaul respirations as the body attempts to correct the acidosis.
D. The vital signs in this option do not reflect the expected findings of DKA, such as tachycardia and deep respirations.
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Explanation
Rationale:
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Correct Answer is A
Explanation
Rationale:
A. NPH insulin is an intermediate-acting insulin that peaks 6-8 hours after administration. Offering a snack at 1500 helps prevent hypoglycemia during the peak action of the insulin.
B. 0730 is too soon after the insulin administration, and the peak effect has not occurred yet.
C. 0900 is still early in the insulin's action, and hypoglycemia is unlikely at this time.
D. 1230 is during the early stages of NPH insulin's action, but hypoglycemia typically does not occur until the peak time later in the day.