A nurse is caring for a client in the emergency department.
Complete the following sentence by using the lists of options.
The nurse should plan to first administer
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Answer: 0.9% Sodium chloride followed by Insulin
The initial treatment for DKA involves fluid resuscitation to address dehydration and electrolyte imbalances, correction of hyperglycemia, and insulin administration to promote glucose utilization and halt ketone production.
Therefore, the nurse should first administer 0.9% sodium chloride (normal saline) to address dehydration and restore intravascular volume, as indicated by the client's low blood pressure (96/65 mm Hg), increased heart rate (110/min), and slight tenting of the skin, suggestive of dehydration.
Once fluid resuscitation is initiated and the client is hemodynamically stable, the next step is to address the hyperkalemia. The client's potassium level is elevated at 5.5 mEq/L, likely due to the acidosis and cellular shift of potassium. Insulin therapy helps to drive potassium back into the cells, thereby lowering serum potassium levels.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Requesting a nightly sedative for a client with dementia is not typically recommended as it may increase the risk of confusion and falls, and sedatives can interfere with normal sleep patterns.
B. Turning off all lights in the room can increase disorientation and confusion in clients with dementia. A nightlight or dim light is usually more appropriate to provide a sense of security and reduce fear.
C. Placing the client's bed at the lowest height helps to reduce the risk of falls and injuries if the client tries to get out of bed independently. This is a practical safety measure for clients with dementia who may have impaired judgment and coordination.
D. Assisting with toileting at least once every 4 hours might not be frequent enough for clients with dementia, who may have difficulty communicating their needs or may forget to use the restroom. Individualized toileting schedules based on the client's needs are more effective.
Correct Answer is C
Explanation
A. IV access is important for potential medication administration and monitoring, but it is not the immediate priority.
B. Aspirin is important for its antiplatelet effects, but nitroglycerin is typically administered first to relieve acute angina symptoms.
C. Administering nitroglycerin helps to relieve angina by dilating coronary arteries and improving blood flow to the heart. It is the first-line treatment for acute angina.
D. Measuring blood pressure is important for assessing the client's condition, but immediate relief of angina symptoms is the priority.
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