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
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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Related Questions
Correct Answer is A
Explanation
Choice A reason:
Palpating the dorsalis pedis pulse is the appropriate option. Checking the dorsalis pedis pulse is crucial to assess the perfusion and circulation to the affected extremity. This is an important nursing action to monitor the patient's vascular status and ensure that there is adequate blood flow to the extremity distal to the fixator. A decrease or absence of the dorsalis pedis pulse could indicate potential circulation issues and require immediate attention.
Choice B reason:
Adjusting the clamps on the fixator frame is incorrect. The nurse should not adjust the clamps without specific orders from the healthcare provider. The external fixator is typically secured according to the surgeon's specifications, and any adjustments should be made under the guidance of the surgical team.
Choice C reason:
Wrapping sterile gauze on the sharp point of the pins is incorrect. The sharp pins used in an external fixator are an integral part of the device and are placed to stabilize the fracture. They should not be covered with sterile gauze, as this could interfere with their function and increase the risk of infection.
Choice D reason:
Maintaining the affected extremity in a dependent position is incorrect. Keeping the affected extremity in a dependent position (lower than the heart) can increase swelling and impair circulation. After surgery and fixation, it's often recommended to elevate the extremity to reduce swelling and promote proper circulation.
Correct Answer is B
Explanation
Choice A Reason:
"Describe your daily medication schedule” is not the correct statement. Understanding the medication schedule is important for adherence to antiretroviral therapy.
Choice B Reason:
"Tell me why it's important to have your CD4+ count checked." Is the correct statement, the priority information for the nurse to review with the client is why it's important to have their CD4+ count checked regularly? The CD4+ count is a crucial marker of immune system health and function in individuals with HIV. Monitoring CD4+ counts help guides treatment decisions, assess the effectiveness of antiretroviral therapy, and evaluate the progression of the disease. Understanding the significance of CD4+ counts is essential for the client's overall management of HIV.
Choice C Reason:
"List some ways you can cope with the stress of your illness" is not the correct statement - Coping strategies are important for the client's emotional well-being and overall health.
Choice D Reason:
"Name a few things you will change about your diet" is not the correct statement. Nutrition is important for overall health, including maintaining a strong immune system, but it may not be the most immediate priority compared to understanding the importance of CD4+ counts.
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