A client with diabetic ketoacidosis (DK
Measure the client's blood pressure manually.
Administer intravenous fluids.
Place the client on oxygen therapy.
Administer subcutaneous insulin.
The Correct Answer is B
Choice A rationale
Measuring blood pressure manually is important in assessing the patient's hemodynamic status, but it is not the priority intervention in diabetic ketoacidosis (DKA). The priority is to address dehydration and electrolyte imbalances.
Choice B rationale
Administering intravenous fluids is the priority intervention for a client with DKA. Rapid, deep respirations (Kussmaul breathing) indicate severe metabolic acidosis and dehydration. IV fluids help to correct fluid deficit, improve perfusion, and decrease blood glucose levels.
Choice C rationale
Oxygen therapy may be beneficial if the client is hypoxic, but it is not the priority intervention for DKA. The primary issue is fluid deficit and metabolic acidosis.
Choice D rationale
Administering subcutaneous insulin is essential for managing hyperglycemia in DKA, but it should be done after initiating IV fluids to avoid rapid shifts in electrolyte balance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Hypertension is not a typical finding associated with community-acquired pneumonia. The condition more commonly presents with respiratory symptoms such as cough, fever, and difficulty breathing.
Choice B rationale
Unequal pupils are not a common finding in community-acquired pneumonia and could indicate a neurological issue or head injury, which would require further investigation.
Choice C rationale
Confusion, particularly in older adults, can be a symptom of community-acquired pneumonia. It is often due to hypoxia or systemic inflammation and is a sign of a more severe infection.
Choice D rationale
Tympany upon chest percussion is not expected in pneumonia. Pneumonia typically presents with dullness on percussion due to the consolidation of lung tissue, not the hyperresonance that causes tympany.
Correct Answer is B
Explanation
Choice A rationale
Increasing fluid intake is contraindicated in clients with fluid overload, such as those with bilateral lower extremity edema and lung crackles. It can worsen the condition.
Choice B rationale
Administering prescribed diuretics is the priority intervention to reduce fluid overload in clients with heart failure post-STEMI. It helps to decrease edema and pulmonary congestion.
Choice C rationale
Applying warm compresses to the lower extremities may provide temporary relief but does not address the underlying issue of fluid overload.
Choice D rationale
Encouraging ambulation is beneficial for overall health but is not a priority intervention for managing fluid overload in this context. .
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