A nurse is caring for a client in the emergency department.
Complete the following sentence by using the lists of options.
The nurse should administer a total of
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Rationale for Correct Choices
• 1 L of 0.9% sodium chloride in the first hour: In diabetic ketoacidosis (DKA), the initial priority is rapid fluid resuscitation to restore intravascular volume and improve tissue perfusion. Administering 1 L of isotonic saline during the first hour helps correct hypotension, tachycardia, and dehydration caused by osmotic diuresis. This bolus stabilizes the client and prepares for subsequent insulin therapy.
• 500 mL each subsequent hour: After the initial fluid bolus, continuing isotonic saline at a slower rate (typically 500 mL per hour) maintains hydration, supports renal perfusion, and gradually corrects electrolyte imbalances. This stepwise approach prevents fluid overload while addressing ongoing losses from polyuria and vomiting.
Rationale for Incorrect Choices
• 2 L in the first hour: Administering 2 L rapidly can cause fluid overload, pulmonary edema, or worsening cardiac strain, especially in clients with potential comorbidities such as hypertension or cardiac dysfunction. A controlled initial bolus of 1 L is safer and evidence-based.
• 500 mL in the first hour: Starting with only 500 mL is insufficient for correcting significant hypovolemia in DKA. Rapid intravascular volume replacement is necessary to prevent shock and improve perfusion.
• 100 mL each subsequent hour: A rate of 100 mL/hr is too slow to meet ongoing fluid needs in a dehydrated client with DKA. Inadequate fluid replacement prolongs hypovolemia, delays renal recovery, and worsens electrolyte imbalances.
• 1 L each subsequent hour: Maintaining a rate of 1 L/hr after the initial bolus may lead to fluid overload, especially in older adults or those with cardiac or renal compromise. A slower maintenance rate of 500 mL/hr balances hydration with safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","F"]
Explanation
A. Administer an enema to promote bowel evacuation: Enemas increase intraluminal pressure and can worsen inflammation or risk perforation in acute diverticulitis. The bowel should be rested during the acute phase to reduce irritation and allow healing. Using an enema can aggravate symptoms and is contraindicated.
B. Prepare to insert a nasogastric tube: The client has nausea, vomiting, abdominal distention, and worsening pain, which can indicate possible ileus or obstruction associated with acute diverticulitis. An NG tube may be needed to decompress the stomach and prevent further vomiting. Preparing for NG tube insertion supports symptom management and prevents complications.
C. Ensure the client is on bed rest: Bed rest decreases bowel activity and reduces discomfort during acute diverticulitis episodes. It helps limit movement that can exacerbate abdominal pain and reduces metabolic demands while the inflammation is being treated.
D. Administer a laxative to prevent constipation: Laxatives stimulate bowel motility, which increases pressure within the colon and can worsen inflammation or risk perforation in acute diverticulitis. These medications are avoided during the acute phase to prevent exacerbation of symptoms or complications.
E. Provide the client with foods that are high in fiber: High-fiber foods help prevent future diverticulitis episodes but are not appropriate during an acute flare. Fiber increases bowel workload and irritation, worsening pain and inflammation. Dietary fiber is introduced only after acute symptoms have resolved.
F. Ensure client is NPO: Keeping the client NPO rests the bowel and reduces stimulation during acute inflammation. NPO status also prepares the client for potential procedures and reduces the risk of worsening symptoms from food intake. This is standard treatment during acute diverticulitis until symptoms improve.
G. Position client in high-Fowler's position: High-Fowler’s position is more useful for clients with respiratory compromise rather than abdominal inflammation. Although sitting upright may provide minor comfort, it does not specifically support management of acute diverticulitis. Supine or semi-Fowler's positions are better tolerated to reduce abdominal strain.
Correct Answer is B
Explanation
A. Contact the client's power of attorney to sign the consent: Involving a power of attorney is not necessary if the client is competent and understands the procedure. The client has the legal right to consent, even if they are unable to read or write.
B. Allow the client to sign the consent with an X: A client who cannot write can legally indicate consent by marking an X on the consent form, as long as they demonstrate understanding of the procedure. This ensures the client’s autonomy and meets legal requirements for informed consent.
C. Notify the surgical team that the client is unable to sign the consent: Simply notifying the team does not address the legal requirement for documented consent. The nurse should facilitate a method for the client to provide valid consent, such as using an X.
D. Inform a family member of the need to sign the consent: Family members should only sign if the client is legally incapable of consenting. Since the client understands the procedure, their own consent is valid, and involving family unnecessarily could violate patient autonomy.
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