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

Administer 0.9% sodium chloride.

Initiate a continuous IV insulin infusion.

Begin bicarbonate continuous IV infusion.

Check potassium levels.

Answer and Explanation

The Correct Answer is B

The priority intervention for a client in DKA is to initiate a continuous IV insulin infusion to lower the blood glucose level and reverse the ketosis. Insulin also helps to correct the electrolyte imbalance and acid-base imbalance in DKA.

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Correct Answer is B

Explanation

Choice a.This response may come across as challenging or confrontational. While the nurse is asking for more information, the phrasing could inadvertently put the client on the defensive. It doesn't validate the client's feelings and may not encourage a productive dialogue.

Choice b. “Suggesting peer support or mentorship from someone who has gone through a similar experience could be beneficial in some situations, as it may help the client feel less isolated.
Choice c. “Most people can adjust following this surgery.” may be true, but it does not acknowledge the client’s individual experience and feelings. It may also sound dismissive or minimizing of the client’s challenges.
Choice d. “You are upset. We can talk about this later.” may be intended to give the client some space, but it does not convey empathy or support. It may also make the client feel rejected or ignored.

A. Administer proparacaine eyedrops into the affected eye. B. Instill 0.9% sodium chloride solution into the affected eye. C. Collect information about the irritant that caused the injury. D. Place a strip of pH paper onto the cul-de-sac of the affected eye.

Correct Answer is C

Explanation

The first action that the nurse should take is to collect information about the irritant that caused the injury, as this will help determine the appropriate treatment and duration of irrigation. Ocular irrigation is the process of flushing the eye with sterile fluid to remove foreign substances or chemicals.

Different types of chemicals may have different effects on the eye, such as acid burns, alkali burns, or organic solvents. Therefore, it is essential to identify the type and concentration of the chemical, as well as the time and duration of the exposure, before proceeding with the irrigation.

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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?

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Naxlex Comprehensive Predictor Exams

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