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 A

Explanation

Choice A reason:When a client expresses concerns about medication, especially antidepressants, the nurse should encourage open communication with the healthcare provider. The provider can assess the situation, address side effects, consider adjusting the dosage, or explore alternative medications if needed.

Choice B reason: Reminding the client of the therapeutic effects is helpful for understanding the benefits of the medication, but it does not provide guidance on how to safely discontinue it.

Choice C reason:Tapering is essential for discontinuation, but it should be done under medical supervision. The nurse should first encourage the client to speak with their provider rather than assuming immediate discontinuation.

Choice D reason: While side effects may dissipate over time, this does not provide a solution for the client who wishes to stop the medication now. It is also not guaranteed that all side effects will diminish.

A. Initiate teaching for client care after discharge. B. Evaluate and update plans of care for clients. C. Begin initial sterile wound care for surgical clients. D. Validate prescribed intravenous flow rates.

Correct Answer is D

Explanation

Choice A reason: Teaching for client care after discharge often involves patient education and planning, which are complex tasks typically reserved for registered nurses due to their scope of practice.

Choice B reason: Evaluating and updating plans of care are responsibilities that involve clinical judgment and are usually performed by registered nurses.

Choice C reason: Initial sterile wound care may require assessment and decision-making that are within the registered nurse's scope of practice.

Choice D reason: Validating prescribed intravenous flow rates is a task that can be delegated to a practical nurse, as it involves monitoring and ensuring that the flow rates are set according to the prescribed orders, which is within the practical nurse's scope of practice.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

After receiving a change of shift report for clients on a medical-surgical unit, which activity should the nurse delegate to the practical nurse (PN)?

Correct Answer is D

Explanation

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