Discover nursing priorities for a child with DKA and signs of altered breathing. Learn to assess leukemia outcomes based on infection control measures.This NCLEX question of the day covers the topic and provides essential information for nursing students and professionals.
The nurse in the intensive care unit is caring for an 11-year-old patient with diabetic ketoacidosis (DKA) with a priority hypothesis of altered breathing pattern. Which finding best supports this hypothesis?
A. Blood glucose 150 mg/dL
B. Serum pH 7.8
C. Tachypnea
D. Hematuria
Scroll down for the correct answers!
The correct answer to today’s NCLEX-RN® Question is…
C. Tachypnea
Rationale: DKA causes metabolic acidosis, so patients can have Kussmaul respirations, where the body automatically increases the respiratory rate, known as tachypnea in an attempt to blow off carbon dioxide and raise the blood pH. This finding supports the priority hypothesis of altered breathing pattern since the patient’s respirations are higher than normal (15-25/min for a school aged child).
Major Takeaway
The nurse should use clinical judgment to evaluate outcomes related to leukemia by comparing observed outcomes against expected outcomes. Patients with leukemia have immature white blood cells that are unable to protect the body against infection. Therefore, patient statements about appropriate infection control measures such as using antibacterial hand gel, bathing daily, and wearing gloves while gardening indicate the outcome was met. On the other hand, using scissors to clip toenails, avoiding the tetanus vaccine, and wearing a mask only when on airplanes are statements that indicate the outcome has not yet been met.
Incorrect answer explanations
A. Blood glucose 150 mg/dL
Rationale: Although patients with uncontrolled type 1 DM can have an elevated blood glucose level, a patient’s blood glucose should be above 250 mg/dL to be considered in DKA. In addition, elevated blood glucose is not an appropriate indicator of the priority hypothesis of altered breathing pattern.
B. Serum pH 7.8
Rationale: In patients with DKA, insulin levels are low so the cells in the body cannot utilize glucose, therefore fat is metabolized for energy instead. The liver breaks down fat into ketone bodies (ketones) and as they build up in the blood, it causes a decrease in pH, leading to metabolic acidosis. So a patient’s pH will be less than 7.35 (normal) rather than higher. Additionally, this serum pH does not best support the priority hypothesis of altered breathing pattern.
D. Hematuria
Rationale: Although patients in DKA will have glucose and ketones in their urine since the renal threshold for resorption is surpassed, they will not have blood in their urine. Further, this finding is not related to the priority hypothesis.
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