A nurse cares for a patient experiencing diabetic ketoacidosis who presents with Kussmaul respirations. What action would the nurse take?

Administration of IV insulin

Implementation of seizure precautions

Administration of oxygen via face mask

Intravenous administration of 10% glucose

Answer and Explanation

The Correct Answer is A

Choice A reason: IV insulin is essential in diabetic ketoacidosis (DKA) to lower blood glucose by facilitating cellular uptake and halting ketogenesis. Kussmaul respirations indicate metabolic acidosis from ketone accumulation. Insulin corrects hyperglycemia and acid-base imbalance, addressing the root cause of DKA by reducing ketone production and restoring metabolic control, critical for patient stabilization.

Choice B reason: Seizure precautions are not indicated for DKA, as seizures are not a primary complication. Kussmaul respirations result from metabolic acidosis, not neurological issues. Implementing seizure precautions diverts attention from addressing hyperglycemia and acidosis, which require insulin and fluid therapy to correct the metabolic derangements causing rapid breathing and systemic instability.

Choice C reason: Oxygen via face mask is unnecessary unless hypoxemia is confirmed. Kussmaul respirations are a compensatory mechanism for metabolic acidosis, not hypoxia. Oxygen does not address the underlying hyperglycemia or ketosis in DKA. The focus should be on insulin and fluids to correct the metabolic acidosis driving the respiratory pattern.

Choice D reason: IV 10% glucose is inappropriate during initial DKA treatment, as patients have hyperglycemia. Administering glucose could worsen hyperglycemia and osmotic diuresis, exacerbating dehydration and acidosis. Insulin and fluids are needed to lower glucose and correct acidosis, with glucose administration considered only if hypoglycemia occurs during treatment, which is not indicated here.

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Correct Answer is C

Explanation

Choice A reason: Respiratory failure is a concern in peritonitis if abdominal distension impairs diaphragm movement, but it is not the highest priority. Sepsis, from bacterial spread, poses a more immediate life-threatening risk, causing systemic inflammation and shock. Monitoring respiratory status is secondary to addressing the infectious source driving peritonitis complications.

Choice B reason: Diabetes is not a direct complication of peritonitis. While it may complicate management by predisposing to infections, peritonitis itself does not cause diabetes. Sepsis is the primary concern, as bacterial peritonitis can rapidly progress to systemic infection, requiring urgent antibiotics and monitoring to prevent multi-organ failure.

Choice C reason: Sepsis is the highest priority in peritonitis, as bacterial contamination from gastrointestinal perforation or infection can lead to systemic inflammatory response syndrome, shock, and organ failure. Early recognition of fever, tachycardia, and hypotension is critical to initiate antibiotics and fluids, preventing mortality in this life-threatening complication of peritonitis.

Choice D reason: Heart attack is not a primary complication of peritonitis. While sepsis may strain the cardiovascular system, increasing myocardial demand, peritonitis itself does not cause coronary occlusion. Sepsis is the more immediate threat, as it drives systemic inflammation and shock, requiring urgent intervention to prevent progression to multi-organ dysfunction.

A. Administer morphine sulfate IV every 4 hours as needed B. Maintain nothing by mouth (NPO) and administer IV fluids C. Place the patient in semi-Fowler’s position with the head of the bed elevated D. Provide small, frequent feedings with no concentrated sweets

Correct Answer is B

Explanation

Choice A reason: Morphine sulfate IV is controversial in pancreatitis, as it may cause sphincter of Oddi spasm, potentially worsening pancreatic duct obstruction and pain. Alternative analgesics like meperidine are preferred. Morphine does not directly promote healing and may complicate pancreatitis management, making it an inappropriate choice for this care plan.

Choice B reason: Maintaining NPO status and administering IV fluids is critical in acute pancreatitis to rest the pancreas, reducing enzyme secretion that exacerbates inflammation. IV fluids correct dehydration from vomiting or third-spacing, supporting hemodynamic stability and promoting healing by minimizing pancreatic stimulation and maintaining perfusion to vital organs.

Choice C reason: Semi-Fowler’s position improves respiratory comfort and reduces abdominal pressure, but it is not the primary intervention for healing in pancreatitis. It aids symptom management, not pancreatic recovery. NPO status and IV fluids directly address the inflammatory process and dehydration, making them more critical for promoting healing in this condition.

Choice D reason: Small, frequent feedings are contraindicated in acute pancreatitis, as oral intake stimulates pancreatic enzyme secretion, worsening inflammation and pain. Patients are kept NPO to rest the pancreas. Feedings may be introduced later in recovery, but during acute phases, this intervention hinders healing and is not included in the care plan.

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A nurse cares for a patient experiencing diabetic ketoacidosis who presents with Kussmaul respirations. What action would the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care for a patient who has peritonitis. Which of the following conditions is the highest priority for the nurse to monitor?

Correct Answer is C

Explanation

A nurse plans care for a patient with acute pancreatitis. Which intervention would the nurse include in the patient’s plan of care to promote healing?

Correct Answer is B

Explanation

A patient admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? (Select all that apply)

The nurse is preparing to educate a group of students on the signs and symptoms of disseminated intravascular coagulation (DIC). The nurse knows that teaching was effective when the students are able to recognize which symptoms as being associated with DIC? (Select all that apply)

A nurse is caring for a patient with acute peritonitis. Which intervention would the nurse expect to see?

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A nurse assesses a patient who is experiencing diabetic ketoacidosis (DKA). Which manifestations would the nurse correlate with DKA? (Select all that apply)

A nurse is caring for a patient with disseminated intravascular coagulation (DIC). Which nursing diagnosis should not be included in this patient’s plan of care?