A patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take?

Correct Answer: C

Rationale: The correct action is to start the prescribed PRN oxygen at 2 to 4 L/min. In diabetic ketoacidosis, rapid, deep respirations are a compensatory mechanism for metabolic acidosis. Administering oxygen helps improve oxygenation and reduces the work of breathing. Encouraging deep slow breaths (choice B) may worsen the patient's condition by interfering with the compensatory mechanism. Giving lorazepam (choice A) is unnecessary and could potentially depress the respiratory drive. Administering fluid bolus and insulin (choice D) are essential treatments for diabetic ketoacidosis, but addressing the respiratory distress with oxygen takes priority in this scenario.

Correct Answer: B

Rationale: The correct answer is B: Test for presence of Chvostek's sign. After a thyroidectomy, tingling around the mouth could indicate hypocalcemia, which can lead to tetany. Chvostek's sign is a test for hypocalcemia, where facial twitching occurs when the facial nerve is tapped. This assessment is crucial to identify potential complications and initiate timely interventions. Incorrect choices: A: Verify the serum potassium level - While electrolyte imbalances can occur post-thyroidectomy, hypocalcemia is more likely to cause the tingling sensation around the mouth. C: Observe for blood on the neck dressing - While assessing for bleeding is important, it does not directly address the tingling sensation reported by the patient. D: Confirm a prescription for thyroid replacement - While important for long-term management post-thyroidectomy, it does not address the immediate concern of tingling sensation related to hypocalcemia.

Correct Answer: B

Rationale: The correct answer is B because an increase in weight indicates fluid retention. In this case, the weight increased from 97.5 kg to 99 kg, suggesting a gain of 1.5 kg, which corresponds to fluid retention of 1.5 liters. Choices A, C, and D are incorrect because they do not accurately reflect the situation described in the question. Choice A does not account for fluid retention, choice C suggests fluid loss despite weight gain, and choice D mentions insensible losses which are not relevant to the weight gain observed.

Correct Answer: D

Rationale: The correct answer is D because dialysis disequilibrium syndrome is a complication that can occur during hemodialysis, presenting with symptoms like headache due to rapid changes in electrolyte levels and osmolarity. The other choices are incorrect because: A: Symptoms mentioned are not specific to dialyzer membrane incompatibility. B: Shift in potassium levels might cause symptoms like muscle weakness or cardiac arrhythmias, not specifically headache. C: A shift in potassium levels is not the primary cause of a headache during hemodialysis.

Correct Answer: C

Rationale: The correct answer is C: Renal ultrasound. Renal ultrasound is a noninvasive diagnostic procedure commonly used to assess kidney function by visualizing the size, shape, and structure of the kidneys. It can detect abnormalities such as kidney stones or cysts. A: Kidney, ureter, bladder (KUB) is an imaging test that provides information on the size and location of the kidneys, ureters, and bladder but does not directly assess kidney function. B: X-ray can show the outline of the kidneys but is not specific for evaluating kidney function. D: Magnetic resonance imaging (MRI) is a more detailed imaging technique that can provide information about kidney structure but is not typically used as a first-line diagnostic tool for routine kidney function assessment.