A client is admitted with diabetic ketoacidosis (DKA) and is receiving an IV infusion of 0.9% sodium chloride and insulin. Two hours later, the client's serum laboratory results show a decrease in the serum blood glucose from 580 to 430 mg/dL (32.2 to 23.86 mmol/L). It is most
important for the nurse to monitor which additional laboratory result?
Reference Range
Serum potassium.
Urine ketones.
Serum sodium.
Blood urea nitrogen (BUN).
The Correct Answer is A
A. Serum potassium. Insulin therapy causes potassium to move into cells, which can lead to hypokalemia. Monitoring serum potassium is critical because significant drops can lead to cardiac arrhythmias and other complications.
B. Urine ketones. While monitoring ketones is important for assessing the resolution of DKA, it is not as immediately critical as monitoring potassium levels.
C. Serum sodium. Sodium levels are important but typically do not change as rapidly as potassium levels during DKA treatment.
D. Blood urea nitrogen (BUN). BUN levels provide information about kidney function and hydration status but are less immediately critical than potassium levels in the context of insulin therapy for DKA.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Test the fluid on the dressing for glucose.
This is the correct action. Clear fluid on a dressing after lumbar spinal surgery could indicate a cerebrospinal fluid (CSF) leak. Testing the fluid for glucose is essential because CSF contains glucose, whereas normal wound drainage does not. A positive glucose test would confirm the presence of CSF, indicating a potential complication that requires immediate medical attention.
B. Mark the drainage area with a pen and continue to monitor.
While monitoring the size of the drainage area can be useful, it is not the immediate priority. The nurse should first determine whether the clear fluid is CSF.
C. Change the dressing using a compression bandage.
Changing the dressing might be necessary, but using a compression bandage without first identifying the nature of the fluid could be inappropriate and potentially harmful if the fluid is CSF.
D. Document the findings in the electronic medical record.
Documentation is important, but it is not the immediate action. The nurse needs to identify the nature of the fluid first.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E","dropdown-group-3":"A"}
Explanation
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Dyspnea: Dyspnea, or difficulty breathing, can be a symptom of an adverse reaction such as an allergic reaction, anaphylaxis, or cardiovascular issues. It indicates a severe reaction that affects the respiratory system and requires immediate attention.
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Nausea: Nausea is a common symptom of adverse reactions to medications or other substances. It can accompany other symptoms like dizziness or headache and indicates that the client is experiencing an ongoing negative reaction to a treatment or exposure.
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Headache: A headache can be a manifestation of various adverse reactions, including those related to medication or changes in blood pressure. It is a significant symptom that may indicate worsening of the client's condition or an ongoing adverse reaction that needs to be addressed.
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