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 C

Explanation

Choice A reason:

Recommending staying at a local shelter might not be appropriate unless the client's health is in immediate danger due to the low temperature. It's better to explore other options first.

Choice B reason:

Contacting the client's family members about their financial status might not be necessary or respectful of the client's privacy without their consent.

Choice C reason:

Contact the local Department of Health and Human Services for the client. Contacting the local Department of Health and Human Services can help ensure that appropriate resources and assistance are provided to the client. They may have programs or services available to assist individuals who are struggling to afford heating during the winter. This action addresses the immediate concern of the client's health and the living environment.

Choice D reason:

Providing information about the dangers of hypothermia is important, but the client's current situation of living in a cold environment should be addressed first. The nurse can provide this information along with appropriate resources to help the client.

A. "Describe your daily medication schedule." B. “Tell me why it's important to have your CD4+ count checked." C. "List some ways you can cope with the stress of your illness." D. “Name a few things you will change about your diet."

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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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

Correct Answer is C

Explanation

A nurse is providing discharge teaching for a client who has HIV. Which of the following information is the priority for the nurse to review with the client?

Correct Answer is B

Explanation

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