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.

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

Explanation

Rationale

Interpretation of Assessment Findings:

Urine ketones:
- DKA
  The presence of urine ketones is a hallmark of diabetic ketoacidosis (DKA), as it indicates the body is breaking down fat for energy due to insufficient insulin. Ketones are typically not present in hyperglycemic-hyperosmolar state (HHS).
Blood glucose greater than expected reference range:
- DKA
- HHS
  Elevated blood glucose levels are consistent with both DKA and HHS. However, blood glucose levels tend to be higher in HHS than in DKA, often exceeding 600 mg/dL in HHS.
Skin turgor:
- DKA
- HHS
  Decreased skin turgor indicates dehydration, which is a common feature in both DKA and HHS due to osmotic diuresis caused by hyperglycemia.
Creatinine greater than expected reference range:
- DKA
- HHS
  Elevated creatinine reflects impaired renal function, often due to dehydration or acute kidney injury, which can occur in both DKA and HHS.
Blood pH:
- DKA
  A blood pH of 7.30 indicates metabolic acidosis, a defining feature of DKA. Blood pH is typically normal in HHS because it does not involve significant ketoacidosis.

A. Metabolic acidosis B. Respiratory acidosis C. Metabolic alkalosis D. Respiratory alkalosis

Correct Answer is C

Explanation

A. Metabolic acidosis is not typically associated with excessive ingestion of antacids. Antacids, especially those containing aluminum, calcium, or magnesium, are more likely to cause alkalosis, not acidosis.

B. Respiratory acidosis is caused by impaired gas exchange (e.g., in conditions like COPD or hypoventilation) and is unrelated to antacid ingestion.

C. Metabolic alkalosis is the correct answer. Excessive ingestion of antacids, particularly those containing sodium bicarbonate or calcium carbonate, can lead to an increase in bicarbonate levels, resulting in metabolic alkalosis. Symptoms can include confusion, muscle twitching, and respiratory depression.

D. Respiratory alkalosis is caused by hyperventilation, not antacid ingestion. It results from excessive loss of carbon dioxide, which is not associated with the use of antacids.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in the emergency department. Exhibits For each assessment finding, click to specify if the assessment finding is consistent with diabetic ketoacidosis (DKA) or hyperglycemic-hyperosmolar state (HHS). Each finding may support more than 1 disease process.

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

Explanation

A nurse in an emergency department is caring for a client who is receiving treatment for excessive ingestion of antacids. The nurse should identify that this client is at risk for which of the following acid-base imbalances?

Correct Answer is C

Explanation

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