A nurse is caring for a client who has diabetic ketoacidosis secondary to an infection. Which of the following prescriptions is the highest priority?

Obtain blood for culture and sensitivity.

Initiate IV infusion of regular insulin.

Initiate 0.9% sodium chloride 1,000 mL IV at 500 mL/hr.

Insert an indwelling urinary catheter.

Answer and Explanation

The Correct Answer is B

A) Obtain blood for culture and sensitivity: While identifying the infection is important for treatment, it does not address the immediate metabolic crisis of diabetic ketoacidosis (DKA). This action is essential but secondary to stabilizing the client's current condition.

B) Initiate IV infusion of regular insulin: Administering insulin is critical in the management of DKA, as it helps to reduce blood glucose levels and halt the production of ketones, which are responsible for the acidosis. This intervention is vital for quickly correcting the metabolic derangement and stabilizing the patient.

C) Initiate 0.9% sodium chloride 1,000 mL IV at 500 mL/hr: While fluid replacement is important in the management of DKA to address dehydration and electrolyte imbalances, it is still not as immediately life-saving as starting insulin therapy. Fluid resuscitation typically follows the administration of insulin.

D) Insert an indwelling urinary catheter: This may be necessary for monitoring urine output and assessing kidney function, but it is not a priority intervention when addressing the acute complications of DKA. Insulin administration takes precedence in the immediate management plan.

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Correct Answer is D

Explanation

A) Elevation in blood pressure: An elevation in blood pressure is not an indicator of the effectiveness of furosemide. In fact, effective diuresis would typically lead to a reduction in blood pressure, especially in cases of pulmonary edema related to heart failure.

B) Respiratory rate of 24/min: A respiratory rate of 24/min indicates tachypnea, which is often associated with respiratory distress or ongoing pulmonary congestion. This finding does not suggest that the furosemide is effective; instead, it may indicate that further intervention is needed.

C) Adventitious breath sounds: The presence of adventitious breath sounds, such as wheezing or crackles, suggests ongoing fluid accumulation in the lungs and is not an indicator of effective diuresis. Effective treatment should lead to clearer breath sounds as fluid is removed.

D) Weight loss of 1.8 kg (4 lb) in the past 24 hr: This finding is a strong indicator of the effectiveness of furosemide. A significant weight loss, especially in a client with pulmonary edema, reflects a reduction in fluid overload. Since furosemide works by promoting diuresis, this weight loss suggests that the medication is effectively reducing excess fluid in the body.

A. Administer an oral opioid for breakthrough pain. B. Encourage family members to press the PCA button for the client. C. Monitor the client's respiratory status every 4 hr. D. Teach the client how to self-medicate using the PCA device.

Correct Answer is D

Explanation

A) Administer an oral opioid for breakthrough pain: While breakthrough pain can occur, using an oral opioid in conjunction with a PCA device is generally not recommended without specific guidance from a healthcare provider. The PCA device is designed to provide continuous pain relief, and adding another opioid could increase the risk of overdose or respiratory depression.

B) Encourage family members to press the PCA button for the client: Family members should not press the PCA button for the client. PCA is meant for self-administration, allowing patients to control their pain relief within prescribed limits. Allowing others to administer the medication could lead to accidental overdosing and potential respiratory depression.

C) Monitor the client's respiratory status every 4 hr: While monitoring respiratory status is crucial, doing so every 4 hours may not be sufficient, especially right after initiating or adjusting PCA therapy. Respiratory status should be monitored more frequently (e.g., every 1 to 2 hours) in the initial phases to catch any signs of respiratory depression early.

D) Teach the client how to self-medicate using the PCA device: This is the most appropriate action. Educating the client about how to use the PCA device empowers them to manage their pain effectively. Understanding the operation, such as the lockout feature and when they can safely press the button, is vital for ensuring effective pain control while minimizing the risk of overdose.

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A nurse is caring for a client who has diabetic ketoacidosis secondary to an infection. Which of the following prescriptions is the highest priority?

Nursing Test Bank

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