A client with diabetic ketoacidosis (DKA) is admitted to the ICU. The nurse notes a fruity breath odor and rapid, deep respirations. Which intervention should the nurse prioritize?

Administer IV insulin

Initiate oral glucose administration

Administer IV sodium bicarbonate

Restrict fluid intake

Answer and Explanation

The Correct Answer is A

Choice A reason: In DKA, hyperglycemia and ketoacidosis cause fruity breath and Kussmaul respirations (rapid, deep breathing) as the body compensates for acidosis. IV insulin halts ketone production, corrects hyperglycemia, and reverses acidosis, addressing the primary metabolic disturbance. This is the priority intervention to stabilize the client and prevent further acid-base imbalance.

Choice B reason: Oral glucose administration is contraindicated in DKA, as it worsens hyperglycemia. Fruity breath and Kussmaul respirations indicate severe metabolic acidosis from ketone accumulation. Insulin is needed to lower blood glucose and stop ketogenesis, making glucose administration harmful and inappropriate for managing this life-threatening condition.

Choice C reason: IV sodium bicarbonate may correct severe acidosis (pH <7.0) in DKA but is not the first-line intervention. Insulin therapy addresses the root cause by reducing hyperglycemia and ketone production, naturally correcting pH. Fruity breath and respirations indicate ongoing acidosis, making insulin the priority over bicarbonate in initial management.

Choice D reason: Restricting fluid intake is contraindicated in DKA, which causes dehydration from osmotic diuresis. Fruity breath and Kussmaul respirations reflect acidosis and compensatory hyperventilation. IV fluids and insulin are needed to restore volume and correct metabolic imbalances, making fluid restriction harmful and inappropriate for this critical condition.

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Correct Answer is D

Explanation

Choice A reason: Oxygen saturation of 88% in COPD is low but may be baseline for severe disease. It warrants oxygen therapy but is not the most urgent finding. Arterial pH of 7.28 indicates acute respiratory acidosis, a life-threatening complication requiring immediate ventilatory support to correct CO2 retention and acid-base imbalance.

Choice B reason: A respiratory rate of 26 breaths/min indicates tachypnea, common in COPD exacerbation, but is not immediately life-threatening. It reflects respiratory effort to compensate for hypoxia. Arterial pH of 7.28 suggests acute acidosis from CO2 retention, requiring urgent intervention like non-invasive ventilation, making tachypnea a lower priority.

Choice C reason: Accessory muscle use indicates increased work of breathing in COPD exacerbation, signaling distress but not immediate danger. It reflects compensatory efforts for airway obstruction. Arterial pH of 7.28 indicates severe acidosis, a life-threatening condition requiring urgent ventilatory support, making muscle use less critical in this scenario.

Choice D reason: Arterial pH of 7.28 in a COPD exacerbation indicates acute respiratory acidosis due to CO2 retention from hypoventilation. This life-threatening imbalance can lead to coma or cardiac arrest if uncorrected. Immediate intervention, such as non-invasive ventilation, is needed to restore pH and CO2 levels, making this the priority finding.

A. Increased glomerular filtration rate, client at risk for fluid overload B. Reduced glomerular filtration rate, client at risk for fluid overload C. Reduced glomerular filtration rate, client at risk for dehydration D. Increased glomerular filtration rate, client at risk for dehydration

Correct Answer is B

Explanation

Choice A reason: A GFR of 40 mL/min/1.73 m² is below normal (≥90), indicating reduced, not increased, kidney function. Chronic renal failure impairs fluid excretion, leading to fluid overload, not dehydration. Increased GFR would suggest hyperfiltration, seen in early diabetes, not chronic renal failure, making this interpretation incorrect.

Choice B reason: A GFR of 40 mL/min/1.73 m² indicates reduced kidney function (Stage 3B chronic kidney disease). The kidneys’ impaired ability to excrete fluid increases the risk of fluid overload, causing edema, hypertension, or pulmonary edema. This aligns with the pathophysiology of chronic renal failure, making this the correct interpretation.

Choice C reason: A GFR of 40 mL/min/1.73 m² reflects reduced kidney function, not dehydration risk. Chronic renal failure leads to fluid retention due to decreased filtration, causing hypervolemia, not hypovolemia. Dehydration is associated with prerenal causes, not established chronic kidney disease, making this interpretation inconsistent with the clinical scenario.

Choice D reason: A GFR of 40 mL/min/1.73 m² is reduced, not increased, in chronic renal failure. Reduced GFR leads to fluid retention, not dehydration, as the kidneys cannot excrete excess fluid. Increased GFR might cause dehydration in rare hyperfiltration states, but this does not apply to chronic renal failure’s pathophysiology.

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