A client with type 1 diabetes mellitus (DM) is admitted to the hospital for an emergency cholecystectomy. The client explains to the nurse about experiencing difficulty at home in keeping blood glucose levels under 200 mg/dl (11.1 mmol/L). To prevent the client from developing diabetic ketoacidosis (DKA), which intervention is most important for the nurse to include in the plan of care?
a) Obtain a fingerstick glucose every 6 hours.
b) Ensure IV fluids are infusing continuously.
c) Test urine for the presence of ketones.
d) Teach the client how to manage sick days.

The correct answer is: c) Test urine for the presence of ketones.

Choice A reason: Obtaining a fingerstick glucose every 6 hours is important for monitoring blood glucose levels and ensuring they are within the target range. However, it is not the most critical intervention for preventing diabetic ketoacidosis. Testing for ketones provides more specific information on the development of DK

Obtain a fingerstick glucose every 6 hours.

Ensure IV fluids are infusing continuously.

Test urine for the presence of ketones.

Teach the client how to manage sick days.

Answer and Explanation

The Correct Answer is C

Choice A reason: Obtaining a fingerstick glucose every 6 hours is important for monitoring blood glucose levels and ensuring they are within the target range. However, it is not the most critical intervention for preventing diabetic ketoacidosis. Testing for ketones provides more specific information on the development of DKA.

Choice B reason: Ensuring IV fluids are infusing continuously is crucial for maintaining hydration and preventing electrolyte imbalances, particularly in a client who may be at risk for DKA. However, this intervention is supportive and not as directly related to detecting the onset of DKA as testing for ketones.

Choice C reason: Testing urine for the presence of ketones is the most important intervention. The presence of ketones indicates that the body is breaking down fat for energy instead of using glucose, which is a hallmark of diabetic ketoacidosis. Early detection of ketones allows for prompt intervention to prevent the progression of DKA.

Choice D reason: Teaching the client how to manage sick days is essential for long-term diabetes management and preventing complications during illness. However, for the immediate prevention of DKA in the hospital setting, testing for ketones is more urgent and directly related to detecting and managing the condition.

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Correct Answer is D

Explanation

Choice A reason: Administering insulin per sliding scale is typically based on blood glucose levels, not just the client's report of hunger. Since the client has already received insulin, providing more insulin without knowing the current blood glucose level could cause hypoglycaemia.

Choice B reason: Starting hourly blood glucose monitoring might be necessary in certain situations, but the immediate need is to address the client's hunger, which could be a sign of impending hypoglycaemia. Addressing the hunger first is more urgent.

Choice C reason: Initiating an IV bolus of 0.9% sodium chloride is not indicated in this scenario. This intervention is typically used for dehydration or other fluid imbalances, not for managing hunger or blood glucose levels directly.

Choice D reason: Providing a snack of cheese and crackers is the most appropriate action. The client's report of hunger after receiving insulin and eating only half of breakfast suggests they might be at risk for hypoglycaemia. A snack will help stabilize their blood glucose levels and prevent hypoglycaemia.

A. Continue the normal saline IV at 75 mL/hour and encourage increased oral fluid intake. B. Slow the normal saline to a keep open rate while contacting the healthcare provider. C. Review the client's medications to see if the client can be given a PRN diuretic. D. Instruct the client to withhold oral fluids and report the symptoms to the provider.

Correct Answer is A

Explanation

Choice A reason: Continuing the normal saline IV at 75 mL/hour and encouraging increased oral fluid intake is the appropriate action. The client is showing signs of dehydration, such as dry mucous membranes and inelastic skin turgor, indicating a need for more fluids. Ensuring proper hydration through both IV and oral routes is essential.

Choice B reason: Slowing the normal saline to a keep open rate while contacting the healthcare provider is not appropriate in this situation. The client needs more fluids, not less. Reducing the IV rate could exacerbate dehydration.

Choice C reason: Reviewing the client's medications to see if the client can be given a PRN diuretic is not suitable for a client showing signs of dehydration. Diuretics would further decrease fluid volume and worsen the symptoms.

Choice D reason: Instructing the client to withhold oral fluids and report the symptoms to the provider is contrary to managing dehydration. The client needs increased fluid intake to address the signs of dehydration effectively.

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Naxlex Comprehensive Predictor Exams

The nurse administers regular insulin SUBQ at 0700 to a client with type 1 diabetes mellitus (DM), after which the client eats one-half of the breakfast provided. At 1000, the client reports being hungry. Which action should the nurse implement?

Correct Answer is D

Explanation

A client who is receiving normal saline IV at 75 mL/hour has dry, sticky mucous membranes, and inelastic skin turgor. Which action should the nurse implement?

Correct Answer is A

Explanation

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