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
A puncture or rupture of the lung is typically associated with a pneumothorax, not flail chest. Pneumothorax occurs when air leaks into the space between the lung and the chest wall.
Choice B rationale
The presence of air or gas in the pleural cavity is known as pneumothorax. Flail chest, however, is characterized by multiple rib fractures.
Choice C rationale
Flail chest occurs when multiple adjacent ribs are fractured in multiple places, creating a free-floating segment of the chest wall. This condition is serious and often results from blunt chest trauma.
Choice D rationale
The collapse of the lung is known as atelectasis or pneumothorax, not flail chest. Flail chest specifically refers to the detachment of a segment of the rib cage.
Correct Answer is D
Explanation
Choice A rationale
Attaching a wristband indicating the client's allergy is a good practice, but it is not the priority action. The priority is to notify the provider to avoid any potential allergic reactions during the procedure.
Choice B rationale
Notifying the dietary department is not relevant in this context. The priority is to ensure the provider is aware of the allergy to prevent an adverse reaction during the cardiac catheterization.
Choice C rationale
Asking the client about other food allergies is important, but the priority action is to notify the provider immediately to ensure the safety of the client during the procedure.
Choice D rationale
Notifying the provider of the client's allergy is the priority action. This ensures that the provider can take necessary precautions to prevent an allergic reaction during the cardiac catheterization procedure.
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