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

A.

Check potassium levels.

B.

Administer 0.9% sodium chloride.

C.

Begin bicarbonate continuous IV infusion.

D.

Initiate a continuous IV insulin infusion.

Answer and Explanation

The Correct Answer is B

A. Checking potassium levels is important in the management of DKA, but it is not the priority intervention. Potassium levels should be monitored closely, as insulin therapy can lower potassium levels, but the first step in treatment is fluid resuscitation.  

B. Administering 0.9% sodium chloride (normal saline) is the priority intervention in DKA. This helps to correct dehydration and restore circulatory volume, which is critical in stabilizing the client. Fluid replacement is the first step in managing DKA before insulin is administered.  

C. Beginning bicarbonate continuous IV infusion is typically not recommended unless the pH is extremely low (below 6.9). The primary treatment in DKA is fluid and insulin therapy, and bicarbonate is used only in severe cases of acidosis.  

D. Initiating a continuous IV insulin infusion is essential in treating DKA, but it should be done after initial fluid resuscitation. Insulin therapy lowers blood glucose and helps to resolve ketosis, but fluid replacement is the first priority to stabilize the client.
 


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Related Questions

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

Rationale:

The client is presenting with chest pain that radiates to the left arm, which is a critical symptom of a potential myocardial infarction (MI). Pain relief is the priority because it is a sign of acute distress and could indicate a life-threatening condition. Addressing the pain level first ensures that the client is more comfortable and allows for better monitoring of other symptoms.

After addressing pain, the nurse should then focus on the client's diaphoresis (excessive sweating), which is another sign of an acute myocardial event. Diaphoresis in the context of chest pain and shortness of breath is often associated with cardiovascular events and requires timely intervention. Managing these symptoms will help stabilize the client while further diagnostic and therapeutic measures are initiated.

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"C"}}

Explanation

  • Pink-tinged urine:
    • Indication of potential worsening condition
      Pink-tinged urine may indicate bleeding in the urinary tract, which could be a complication of the urinary tract infection (UTI) or another underlying issue.
  • Hct 45%:
    • Indication of potential improvement
      The hematocrit has decreased from 50% to 45%, suggesting improved hydration status, as the previous elevated Hct was likely due to hemoconcentration.
  • Butterfly rash:
    • Unrelated to diagnosis
      The butterfly rash is a hallmark sign of systemic lupus erythematosus (SLE), part of the client's medical history, but it is unrelated to the current UTI diagnosis.
  • Oxygen saturation 96% at 2 L/min via nasal cannula:
    • Indication of potential improvement
      The oxygen saturation has improved from 95% on 3 L/min to 96% on 2 L/min, suggesting better respiratory status and gas exchange.
  • Blood pressure 100/50 mm Hg:
    • Indication of potential worsening condition
      The blood pressure has decreased from 106/64 mm Hg to 100/50 mm Hg, which may indicate worsening perfusion or ongoing dehydration.
  • Disoriented to person, place, and time:
    • Indication of potential worsening condition
      The client was previously oriented to person and place but is now disoriented. This could indicate worsening infection, progression to sepsis, or other complications such as hypoxia or electrolyte imbalance.

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