A nurse is caring for a client who is experiencing diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse?
Check potassium levels.
Administer 0.9% sodium chloride.
Begin bicarbonate continuous IV infusion.
Initiate a continuous IV insulin infusion.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
Rationale
Client is alert and oriented x4, heart and lung sounds clear.
This shows that the client is stable and no longer experiencing confusion or respiratory distress, which are signs of improvement.
Client is tolerating soft diet and oral fluids.
The ability to tolerate food and fluids is a sign of recovery and better overall condition
Correct Answer is A
Explanation
A. Respite care services provide temporary relief for caregivers, allowing them to take breaks and avoid burnout. This recommendation addresses the caregiver's fatigue and stress, helping to prevent caregiver exhaustion and improve their well-being.
B. Hospice services are appropriate for end-of-life care, but the client with moderate Alzheimer's disease is not at the end of life, so this is not the most appropriate recommendation at this stage.
C. Pursuing local protective services is necessary if there is evidence of abuse or neglect. However, the issue here seems to be caregiver stress, not abuse, so this action is not warranted.
D. Taking a nonprescription sleeping medication might address some symptoms of fatigue but does not address the underlying issue of caregiver burnout. Respite care is a more effective solution for the caregiver's needs.
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