A client with diabetic ketoacidosis (DKA) 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). What additional laboratory result is most important for the nurse to monitor?
Serum sodium.
Serum potassium.
Blood urea nitrogen (BUN).
Urine ketones.
The Correct Answer is B
Choice A rationale
While monitoring serum sodium levels is important in a client with DKA, it is not the most critical. Hyperglycemia can lead to a state of effective osmotic diuresis, which can cause sodium depletion.
Choice B rationale
Serum potassium levels are crucial to monitor in a client with DKA3. Despite total body potassium depletion, serum potassium levels may be high or normal upon presentation due to acidosis and insulin deficiency. However, with insulin treatment, potassium will shift back into the cells, potentially leading to life-threatening hypokalemia.
Choice C rationale
Blood urea nitrogen (BUN) might be elevated due to dehydration, but it is not the most critical lab value to monitor in the management of DKA3.
Choice D rationale
Urine ketones are not as important to monitor as serum potassium in DKA. The presence of ketones in urine only confirms that the body is breaking down fat, not the severity of DKA3.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
If a patient suddenly experiences numbness and weakness on the right side of their body, including their arm and leg, and a distinct droop on the right side of the patient’s face, these are warning signs of a stroke. The nurse’s first course of action should be to initiate two large- bore IV catheters and review the inclusion criteria for IV fibrinolytic therapy. This is because rapid administration of fibrinolytic therapy can significantly improve outcomes in patients with acute ischemic stroke.
Choice B rationale
Continuous observation for transient episodes of neurologic dysfunction is important, but the immediate priority is to prepare for potential fibrinolytic therapy.
Choice C rationale
Elevating the head of the bed to 30 degrees and keeping the head and neck in neutral alignment can be beneficial in certain situations, but it is not the immediate priority in this scenario.
Choice D rationale
Administering aspirin can help prevent further clot formation and platelet aggregation in patients with acute coronary syndrome or those at high risk of cardiovascular disease.
However, in the case of a suspected stroke, immediate medical evaluation and potential fibrinolytic therapy are the priorities.
Correct Answer is D
Explanation
Choice A rationale
Mixing the dextrose in a 50 mL piggyback for a total volume of 100 mL is not the best method for administering the medication. This would dilute the dextrose, potentially reducing its effectiveness.
Choice B rationale
Diluting the dextrose in one liter of 0.9% normal saline solution is not the best method for administering the medication. This would significantly dilute the dextrose, potentially reducing its effectiveness.
Choice C rationale
Asking the pharmacist to add the dextrose to a total parenteral nutrition (TPN) solution is not the best method for administering the medication. This would not provide the immediate glucose boost needed to counteract insulin shock.
Choice D rationale
Pushing the undiluted dextrose slowly through the currently infusing IV is the best method for administering the medication. This allows for rapid administration of a concentrated glucose solution, which is necessary to quickly raise blood glucose levels in a patient experiencing insulin shock.
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