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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Lifting weights every other day might not be harmful, but it is not specifically relevant to managing chronic venous insufficiency. The statement does not indicate an understanding of the specific care needed for this condition.

Choice B reason: Avoiding sitting and crossing the legs is an important measure to prevent worsening of chronic venous insufficiency. Crossing legs can impede blood flow and worsen symptoms. This statement reflects an understanding of how to manage the condition.

Choice C reason: Standing for prolonged periods, even if there is no pain, can exacerbate venous insufficiency. This statement shows a misunderstanding of the importance of movement and elevation of the legs to promote blood flow.

Choice D reason: Walking is generally encouraged to promote circulation in clients with venous insufficiency. The statement about needing someone else to walk the dog may indicate a misunderstanding of the benefits of regular, gentle exercise.

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.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with chronic venous insufficiency is being discharged from the hospital and plans to return home. Which client statement indicates an understanding of home care instructions?

Correct Answer is B

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

An adult client has been admitted to the hospital with asthma exacerbation. Which trigger should the nurse identify as being the most significant cause of this client's asthma complications?

Which statement by a client with systemic lupus erythematosus (SLE) indicates the best understanding of proper skin care?

The nurse calculates the body mass index (BMI) for an adult client who is obese. Which additional assessment finding places the client at high risk for cardiac disease?

The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?

The nurse is obtaining a health history from a new client who has a history of kidney stones. Which statement by the client indicates an increased risk for renal calculi?

The practical nurse (PN) reports to the charge nurse that a client who is receiving a parenteral nutrition infusion has a capillary glucose of 365 mg/dL (20.3 mmol/L). Which action should the charge nurse implement?