A nurse in an emergency department is caring for a client whose blood glucose level indicates diabetic ketoacidosis. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Check the client's airway and level of consciousness.

Assess vital signs to determine hydration status.

Administer prescribed IV fluids.

Monitor for pulmonary edema.

Answer and Explanation

The Correct Answer is A,B,C,D

Rationale:

A. Check the client's airway and level of consciousness: The first priority is to assess the client's airway and level of consciousness to ensure that they are breathing properly and to gauge the severity of the condition.

B. Assess vital signs to determine hydration status: After assessing the airway and consciousness, it’s crucial to evaluate vital signs to determine the client's hydration status, as dehydration is a significant concern in diabetic ketoacidosis.

C. Administer prescribed IV fluids: IV fluids should be administered promptly to treat dehydration, restore electrolyte balance, and help improve circulation. This is typically the next step after assessing vital signs and hydration status.

D. Monitor for pulmonary edema: Once the IV fluids are being administered, the nurse should monitor for potential complications, such as pulmonary edema, which can occur due to fluid overload or other factors related to treatment.

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Correct Answer is C

Explanation

Rationale:

A. Flumazenil: Flumazenil is used to reverse the effects of benzodiazepines, not opioids like morphine. It would not be effective in this situation since the client is experiencing respiratory depression due to morphine use.

B. Diphenhydramine: Diphenhydramine is an antihistamine, and while it may help with symptoms like itching, it does not reverse respiratory depression caused by opioids. It is not appropriate for this scenario.

C. Naloxone: Naloxone is an opioid antagonist used to reverse the effects of opioid overdose, including respiratory depression. It is the appropriate medication to administer in this situation to quickly reverse the respiratory depression caused by morphine.

D. Calcium gluconate: Calcium gluconate is used to treat calcium channel blocker overdose or certain types of hyperkalemia, but it is not effective for reversing respiratory depression caused by opioids.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

Rationale for Correct Choices:

Antibiotic therapy: The client’s symptoms (flank pain, painful urination, reddish-brown urine), elevated white blood cell count (15,000/mm³), positive nitrites, leukocyte esterase, and blood in the urine suggest a urinary tract infection (UTI) or pyelonephritis. Antibiotics are needed to treat this infection.
Urinary tract infection: The urinalysis findings of turbid, dark red urine with blood, positive nitrites, and leukocyte esterase, along with symptoms like painful urination, flank pain, and fever, strongly point to a UTI, possibly involving the kidneys.

Rationale for Incorrect Choices:

Lithotripsy: Lithotripsy is used for kidney stones, but the client’s symptoms don’t suggest kidney stones, as there is no sharp, colicky pain. The symptoms are more aligned with a UTI.
Indwelling urinary catheter: An indwelling catheter is not needed for this UTI unless there’s urinary retention. The client's main issue is a UTI, and there is no mention of retention or obstruction requiring a catheter.
Kidney failure: Although BUN and creatinine are elevated, the primary issue is a UTI, not kidney failure. Kidney failure would be characterized by more severe, prolonged renal dysfunction.
Pneumonia: The symptoms do not suggest pneumonia. The primary symptoms of pneumonia include cough and difficulty breathing, which are not present here. Crackles are more likely due to fluid overload.

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A nurse in an emergency department is caring for a client whose blood glucose level indicates diabetic ketoacidosis. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative and develops respiratory depression after receiving morphine for pain control. Which of the following medications should the nurse expect the provider to prescribe?

Correct Answer is C

Explanation

The nurse is caring for a client in the emergency department. Exhibits Complete the following sentence by using the lists of options. The nurse should anticipate a provider order for client's dropdown due to the client's dropdown .

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

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