A nurse in the emergency department is admitting a client who has diabetic ketoacidosis and a blood glucose level of 800 mg/dL. Which of the following interventions should the nurse initiate first?
Potassium chloride 10 mEq/hr
Bicarbonate by IV infusion
Subcutaneous insulin injections
0.9% sodium chloride 15 mL/kg/hr
The Correct Answer is D
Choice A rationale: While potassium replacement is important in diabetic ketoacidosis, fluid resuscitation to restore intravascular volume, improve renal perfusion, and flush out ketones.
Choice B rationale: Bicarbonate infusion might be considered in severe acidosis, but fluid administration is the priority.
Choice C rationale: The priority intervention for a client with diabetic ketoacidosis and very high blood glucose levels is to initiate fluid resuscitation to restore intravascular volume, improve renal perfusion, and flush out ketones.
Choice D rationale: The first intervention the nurse should initiate is fluid resuscitation with 0.9% sodium chloride at a rate of 15 mL/kg/hr to restore intravascular volume, improve renal perfusion, and flush out ketones.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Myoclonic seizures are not typically associated with neostigmine administration.
Choice B rationale: Fever is not a common adverse effect of neostigmine.
Choice C rationale: Neostigmine, a cholinesterase inhibitor, can lead to excessive muscarinic responses like increased salivation due to its effects on cholinergic receptors.
Choice D rationale: Occipital headaches are not typically reported as a response to neostigmine.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale: For subcutaneous injections like enoxaparin, the entire length of the needle needs to be inserted to ensure that the medication reaches the fatty tissue under the skin and reduces the risk of bleeding or bruising.
Choice B rationale: The client should not massage the insertion site after injecting the medication, as this may increase the risk of hematoma formation.
Choice C rationale: The client should alternate injection sites between the sides of the abdomen to prevent bruising and irritation.
Choice D rationale: The client should also grasp the skin between the thumb and forefinger while injecting the medication to create a fold of tissue. This ensures that the medication is delivered into the subcutaneous layer and not the muscle.
Choice E rationale: The client should not expel the air bubble from the prefilled syringe, as this helps to seal the medication in the tissue and prevent leakage while ensuring that you receive the full dose of medication.
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