A nurse is caring for a client in diabetic ketoacidosis (DKA).
Which of the following is the priority intervention by the nurse?
Check potassium levels.
Begin bicarbonate continuous IV infusion.
Initiate a continuous IV insulin infusion.
Administer 0.9% sodium chloride.
The Correct Answer is D
The correct answer is Choice D.
Choice A rationale: Checking potassium levels is important in the management of DKA, but it is not the priority intervention. The priority intervention is to restore intravascular volume with fluid resuscitation
Choice B rationale: Bicarbonate infusion is not the priority intervention in the management of DKA. It is used only in severe cases of metabolic acidosis
Choice C rationale: Initiation of a continuous IV insulin infusion is an important intervention in the management of DKA, but it is not the priority intervention. The priority intervention is to restore intravascular volume with fluid resuscitation
Choice D rationale: Administering 0.9% sodium chloride is the priority intervention in the management of DKA. It is used to restore intravascular volume and correct electrolyte imbalances
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A decrease in the Glasgow Coma Scale (GCS) score indicates a decline in the client’s level of consciousness and neurological function.
This can be a sign of increased intracranial pressure or other complications related to the skull fracture.
Choice B is incorrect because an increase in WBC count may indicate an infection, but it is not as concerning as a decrease in GCS score.
Choice C is incorrect because a change in pulse pressure may indicate changes in cardiovascular function, but it is not as concerning as a decrease in GCS score.
Choice D is incorrect because a change in pupil diameter may indicate changes in neurological function, but it is not as concerning as a decrease in GCS score.
Correct Answer is C
Explanation
The nurse should plan to notify the Rapid Response Team first.
The client’s blood pressure is elevated, heart rate is high, respiratory rate is high, and oxygen saturation is low.
These are all signs of potential instability and the Rapid Response Team should be notified immediately.
Choice A is incorrect because while obtaining an ECG may be important, it is not the nurse’s first priority in this situation.
Choice B is incorrect because while calculating the extent of burns using the rule of nines may be important, it is not the nurse’s first priority in this situation.
Choice D is incorrect because while initiating peripheral IV access may be important, it is not the nurse’s first priority in this situation.
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