A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse?

initiate a continuous IV insulin infusion

Begin bicarbonate continuous IV infusion

Check potassium levels

Administer 0.9% sodium chloride

Answer and Explanation

The Correct Answer is A

Choice A reason:

Initiating a continuous IV insulin infusion is the first priority. The priority intervention for a client in diabetic ketoacidosis (DKA) is to normalize blood glucose levels and reverse the ketoacidosis. Initiating a continuous IV insulin infusion is essential to rapidly lower the elevated blood glucose levels and counteract the metabolic acidosis associated with DKA.

Choice B reason:

Beginning a bicarbonate continuous IV infusion is generally not the priority in DKA management. While metabolic acidosis is a concern in DKA, insulin therapy and fluid resuscitation are typically the initial focus of treatment.

Choice C reason:

Checking potassium levels is important since potassium imbalances are common in DKA. However, while this is important, it is not the first priority. It's important to ensure that insulin therapy has been initiated before addressing potassium levels.

Choice D reason:

Administering 0.9% sodium chloride (normal saline) is a crucial part of DKA treatment but it is not the first priority as it helps correct dehydration and electrolyte imbalances. However, starting insulin therapy to address the underlying metabolic issue takes precedence.

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Correct Answer is B

Explanation

Choice A reason:

Listening to the client's bowel sounds should not be implemented. It is important for assessing the gastrointestinal status, but the priority in this situation is to address the potential cardiac complications of hypokalaemia.

Choice B reason:

Initiating cardiac monitoring for the client should be implemented. A serum potassium level of 2.8 mEq/L is significantly low (normal range is typically around 3.5-5.0 mEq/L). Low potassium levels, known as hypokalaemia, can lead to serious cardiac arrhythmias and other complications. Therefore, the nurse should prioritize cardiac monitoring to assess for any potential changes or abnormalities in the client's heart rhythm due to the low potassium levels.

Choice C reason:

Checking the client's hand grasps should not be implemented. It is a test for muscle strength and can be indicative of hypokalaemia, but initiating cardiac monitoring is more critical at this point.

Choice D reason:

Administering an IV potassium drip may be necessary, but initiating cardiac monitoring takes precedence as the first action to ensure the client's heart rhythm is stable before addressing the potassium imbalance.

A. "I can drink vegetable juice with a meal." B. “can have mayonnaise on my sandwiches." C. " can season my foods with garlic and onion salts” D. "I can have a frozen fruit juice bar for dessert”

Correct Answer is A

Explanation

Choice A Reason:

"I can drink vegetable juice with a meal."

Limiting sodium intake is a crucial part of managing heart failure, as excess sodium can lead to fluid retention and exacerbation of symptoms. Among the options provided, drinking vegetable juice with a meal is the one that suggests the client understands the need to limit sodium intake. Fresh vegetable juice typically has lower sodium content compared to other options, and incorporating it into meals can help the client manage their sodium intake.

Choice B Reason:

"I can have mayonnaise on my sandwiches." - Mayonnaise is often high in sodium and is not typically recommended in a low-sodium diet.

Choice C Reason:

"I can season my foods with garlic and onion salts." - Garlic and onion salts are often high in sodium. It's better to use fresh herbs and spices for seasoning.

Choice D Reason:

"I can have a frozen fruit juice bar for dessert." - Frozen fruit juice bars might contain added sugars or high sodium content. It's important to check the nutrition label for sodium content before consuming such items.

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A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who arrives at the emergency department and reports vomiting and diarrhea for the past 3 days. The client's serum potassium level is 2.8 mEq/L. Which of the following interventions should the nurse implement first?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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