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
“The client’s capillary refill in the left toe is 6 seconds.” Capillary refill time is the time it takes for blood to return to the capillaries after pressure has been applied to the skin.
A normal capillary refill time is less than 2 seconds.
A capillary refill time of 6 seconds indicates poor blood flow to the left toe and requires immediate intervention by the nurse.
Choice B is not the correct answer because while a pain level of 7 on a scale from 0 to 10 at the operative site is concerning, it does not require immediate intervention by the nurse.
Choice C is not the correct answer because an oral temperature of 38.3° C (100.9° F) is only slightly elevated and does not require immediate intervention by the nurse.
Choice D is not the correct answer because while 100 mL of blood in a closed-suction drain may be concerning, it does not necessarily require immediate intervention by the nurse.
Correct Answer is C
Explanation
Step 1: 100 mL ÷ 30 min
Step 2: (100 mL ÷ 30 min) × 60 min/hr
Step 3: 3.33 mL/min × 60 min/hr
Answer: 200 mL/hr
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