Level: Clinical
Difficulty: Medium
Subtopic: Hypoxia and impaired gas exchange
NCLEX: A 73-year-old client on a telemetry unit is being evaluated for nursing care related to hypoxia and impaired gas…
Pathophysiology Physiological Adaptation
Case Study
A 73-year-old client on a telemetry unit is being evaluated for nursing care related to hypoxia and impaired gas exchange. Assessment data include blood glucose 420 mg/dL with acetone breath and Kussmaul respirations. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. The new finding that blood glucose 420 mg/dL with acetone breath and Kussmaul respirations.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
B. The new finding that blood glucose 420 mg/dL with acetone breath and Kussmaul respirations.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: B. The new finding that blood glucose 420 mg/dL with acetone breath and Kussmaul respirations.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.