A home health nurse is teaching a client who has heart failure. Which of the following responses should the nurse identify as an indication that the client understands the teaching?

Rationale:

A. Regular insulin continuous intravenous infusion, titrate per diabetic ketoacidosis (DKA) protocol once potassium is greater than 3.3 mEq/L: A continuous IV insulin infusion is required in DKA to reduce blood glucose and correct ketosis rapidly. It is started after ensuring potassium levels are above 3.3 mEq/L to prevent hypokalemia.

B. Regular insulin 20 units subcutaneously: Subcutaneous insulin is slower acting and inappropriate for managing DKA, where rapid glucose control is needed. IV insulin provides immediate action, which is essential for treating DKA effectively.

C. Blood glucose checks every 4 hr: Blood glucose needs to be checked more frequently, every 1–2 hours, to adjust the insulin infusion rate. Every 4-hour checks are not sufficient for managing the fluctuating glucose levels in DKA.

D. Initiate cardiac monitoring: Cardiac monitoring is essential due to potential electrolyte imbalances, especially potassium, which can lead to arrhythmias. Elevated or fluctuating potassium levels in DKA increase the risk of serious heart disturbances.

E. 0.9% sodium chloride at 15 ml/kg/hr for 1 hr and then reduce to 10 ml/kg/hr: Fluid resuscitation with isotonic saline addresses dehydration caused by hyperglycemia. The initial rate is higher to restore circulatory volume, and after the first hour, the rate is reduced to maintain hydration.

F. Insert indwelling urinary catheter: A urinary catheter is not needed unless there's a concern about urinary retention or precise output monitoring. The priority is fluid management, insulin therapy, and electrolyte monitoring in DKA.

G. Potassium chloride 20 mEq/L intravenous PRN potassium less than 5.0 mEq/L: The client currently has hyperkalemia (5.5 mEq/L). Administering additional potassium chloride at this time would be contraindicated and could worsen the hyperkalemia, potentially leading to dangerous cardiac arrhythmias.

H. Dextrose 5% in water (DSW) intravenous at 5 ml/kg/hr for 4 hr: Dextrose is not given initially in DKA unless blood glucose is dangerously low. The primary focus is on lowering blood glucose with insulin and correcting ketosis.

Rationale:

A. Provide analgesic medication prior to physical activities: Administering analgesic medication prior to physical activities helps facilitate recovery by minimizing pain, which can encourage the client to engage in necessary activities such as deep breathing, coughing, and ambulation to prevent complications like pneumonia or blood clots.

B. Administer naloxone if the client's respiratory rate is greater than 24/min: Naloxone is used to reverse opioid overdose, particularly if the respiratory rate is low (less than 12/min). A respiratory rate greater than 24/min does not require naloxone administration.

C. Withhold analgesic medication unless the client reports pain: Withholding analgesics can hinder the client's ability to participate in activities necessary for recovery. Managing pain proactively, rather than reactively, is essential to help the client with early mobilization.

D. Inform the client to monitor for loose stools while taking opioid analgesia: Opioids are more likely to cause constipation rather than loose stools. Clients taking opioid analgesia should be informed about the risk of constipation..