A client is admitted with diabetic ketoacidosis (DKA).
The nurse should anticipate administering which of the following intravenous fluids (Select all that apply).
0.45% sodium chloride solution.
0.9% sodium chloride solution.
5% dextrose in water solution.
Lactated Ringer’s solution.
Regular insulin infusion.
Correct Answer : A,B,E
The nurse should anticipate administering 0.9% sodium chloride solution and regular insulin infusion to a client with diabetic ketoacidosis (DKA).
Choice A is wrong because 0.45% sodium chloride solution is a hypotonic fluid that can cause cerebral edema in DKA patients.
Choice C is wrong because 5% dextrose in water solution can increase blood glucose levels and worsen hyperglycemia in DKA patients.
Choice D is wrong because lactated Ringer’s solution contains lactate, which can be converted to bicarbonate and cause metabolic alkalosis in DKA patients.
Normal ranges for blood glucose, pH, bicarbonate, and ketones are as follows3: Blood glucose: 70-130 mg/dL before meals, and less than 180 mg/dL after meals pH: 7.35-7.45
Bicarbonate: 22-26 mEq/L Ketones: negative or trace
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is because urinary catheters are a common source of catheter associated urinary tract infections (CAUTIs), which can lead to complications such as pyelonephritis, sepsis, and renal failure. Therefore, the nurse should remove the catheter as soon as possible to reduce the risk of infection and promote normal urinary function.
Choice B is wrong because ensuring that the catheter is properly secured to prevent accidental dislodgement is not a priority intervention for a patient with a urinary catheter.
While this is an important nursing action to prevent trauma and bleeding, it does not address the main complication of catheterization, which is infection.
Choice C is wrong because encouraging the patient to drink fluids to prevent dehydration is not a priority intervention for a patient with a urinary catheter.
While this is a good nursing practice to maintain hydration and renal perfusion, it does not affect the risk of infection associated with catheterization.
Choice D is wrong because administering antibiotics to prevent infection is not a priority intervention for a patient with a urinary catheter.
While this may be indicated for some patients who have signs and symptoms of UTI or who are at high risk of infection, it is not a routine measure for all patients with catheters and may contribute to antibiotic resistance.
Correct Answer is A
Explanation
Metabolic acidosis is a condition in which there is excess acid in the body fluids.
It causes rapid breathing, confusion, tiredness, headache, and increased heart rate.
Rapid breathing is a compensatory mechanism that helps to lower the carbon dioxide levels and increase the pH of the blood.
Choice B is wrong because decreased respiratory rate would worsen the acidosis by retaining more carbon dioxide and lowering the pH of the blood.
Choice C is wrong because normal respiratory rate would not be adequate to compensate for the metabolic acidosis and would result in acidemia (low blood pH).
Choice D is wrong because irregular respiratory rate is not a typical response to metabolic acidosis and could indicate other problems such as brain injury or drug overdose.
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