A client with type 1 diabetes mellitus (DM) is admitted in diabetic ketoacidosis. Treatment is initiated, and the nurse is preparing to administer IV fluids containing potassium chloride. Which assessment data is most important for the nurse to obtain before starting the infusion?

Urinary output of 30 to 60 mL/hr.

Magnesium level.

Size of the IV catheter.

Serum glucose level.

Answer and Explanation

The Correct Answer is A

Choice A reason: Before administering IV fluids containing potassium chloride, it is crucial to ensure that the client has adequate urinary output, typically between 30 to 60 mL/hr. This indicates good kidney function, which is necessary for the excretion of potassium to prevent hyperkalemia, a potentially life-threatening condition.

Choice B reason: While magnesium levels can affect potassium levels, they are not the most critical assessment before potassium infusion. However, it is important to monitor magnesium levels as part of the overall electrolyte balance, especially in diabetic ketoacidosis.

Choice C reason: The size of the IV catheter is important for administration purposes, but it is not the most critical assessment data before starting potassium infusion. The catheter size affects the flow rate and comfort during infusion but does not impact the decision to start the infusion.

Choice D reason: Serum glucose level is a vital parameter to monitor in diabetic ketoacidosis, but it is not the most critical assessment before starting potassium infusion. The primary concern with potassium infusion is kidney function, as assessed by urinary output.

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Correct Answer is C

Explanation

Choice A reason: Decreased bowel sounds may indicate gastrointestinal issues but are not directly related to weight gain associated with fluid accumulation in cirrhosis.

Choice B reason: An increased respiratory rate can be a sign of many conditions, including respiratory distress, but it does not correlate specifically with weight gain due to fluid retention in cirrhosis.

Choice C reason: Increased abdominal girth is a common finding in cirrhosis due to ascites, which is the accumulation of fluid in the peritoneal cavity and can lead to significant weight gain.

Choice D reason: Decreased level of consciousness may be a sign of hepatic encephalopathy in cirrhosis but is not a direct correlation to the weight gain reported by the client.

A. Assume care of the client and assign the PN to the care of a different client. B. Arrange for unlicensed assistive personnel to assist the PN during the procedure. C. Acknowledge that the PN has positioned the client safely and correctly. D. Demonstrate to the PN how to position the client more effectively for the procedure.

Correct Answer is D

Explanation

Choice A reason: Assuming care of the client and reassigning the PN does not address the immediate need to correct the client's position for the sigmoidoscopy.

Choice B reason: While assistance may be needed, it is more important to first ensure that the client is in the correct position for the procedure.

Choice C reason: Acknowledging the PN's action would be incorrect since the client has not been positioned safely and correctly for a sigmoidoscopy.

Choice D reason: Demonstrating the correct positioning ensures the procedure can be performed effectively and safely, which is the nurse's immediate responsibility.

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A client with type 1 diabetes mellitus (DM) is admitted in diabetic ketoacidosis. Treatment is initiated, and the nurse is preparing to administer IV fluids containing potassium chloride. Which assessment data is most important for the nurse to obtain before starting the infusion?

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