A nurse is caring for a client with diabetic ketoacidosis (DKA). Which of the following interventions is the priority?
Administer insulin infusion
Provide oral glucose
Administer sodium bicarbonate
Encourage deep breathing exercises
The Correct Answer is A
Choice A reason: Administering insulin infusion is the priority in DKA to correct hyperglycemia and halt ketogenesis. Insulin lowers blood glucose by facilitating cellular uptake and inhibits lipolysis, reducing ketone production. This addresses the underlying metabolic derangement, preventing further acidosis and stabilizing the patient’s condition rapidly, critical for life-threatening DKA.
Choice B reason: Providing oral glucose is contraindicated in DKA, as the client already has severe hyperglycemia. Adding glucose would worsen the condition, increasing osmotic diuresis and acidosis. The focus is on lowering blood sugar with insulin and fluids, not adding more glucose, which could exacerbate dehydration and metabolic imbalance.
Choice C reason: Sodium bicarbonate may be used in severe DKA with profound acidosis (pH < 7.0), but it is not the priority. Insulin and fluid resuscitation correct the underlying cause of acidosis by stopping ketone production and restoring perfusion. Bicarbonate is an adjunct and may cause complications like hypokalemia if used prematurely.
Choice D reason: Deep breathing exercises do not address the metabolic cause of DKA. While compensatory hyperventilation (Kussmaul respirations) occurs to correct acidosis, encouraging breathing exercises does not treat hyperglycemia or ketosis. Insulin and fluids are critical to reverse the underlying pathology, making breathing exercises a low-priority intervention in this acute condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A reason: Collecting sputum specimens for acid-fast bacilli (AFB) testing over three consecutive mornings is critical for diagnosing active tuberculosis. AFB smear and culture detect Mycobacterium tuberculosis in sputum, confirming pulmonary TB. Morning samples yield higher bacterial loads, improving diagnostic sensitivity, as the bacteria accumulate overnight in the respiratory tract.
Choice B reason: Monitoring vital signs every shift is important for assessing patient stability but does not directly aid in diagnosing active tuberculosis. Fever or tachycardia may suggest infection, but these are non-specific and not confirmatory. Diagnostic tests like AFB, imaging, or serology are needed to identify Mycobacterium tuberculosis as the cause of symptoms.
Choice C reason: Ordering a complete blood count, basic metabolic panel, HIV viral load, and VDRL supports TB diagnosis. CBC may show anemia or leukocytosis, BMP assesses organ function, HIV testing identifies immunosuppression increasing TB risk, and VDRL rules out syphilis, which can mimic TB symptoms. These provide a comprehensive diagnostic workup.
Choice D reason: A chest X-ray is essential for diagnosing active pulmonary tuberculosis. It reveals characteristic findings like cavitary lesions, infiltrates, or hilar lymphadenopathy in the lungs. These radiographic signs, combined with clinical symptoms and AFB testing, confirm the presence of active TB, particularly in patients with cough and weight loss.
Choice E reason: Admitting the patient to a negative pressure room is crucial for diagnosing and managing suspected active TB. It prevents airborne transmission of Mycobacterium tuberculosis to others, ensuring safety while diagnostic tests like AFB and chest X-ray are conducted. This isolation is standard for suspected infectious TB cases.
Correct Answer is A
Explanation
Choice A reason: Elevated amylase and lipase are hallmark findings in acute pancreatitis. Pancreatic inflammation causes enzyme leakage into the bloodstream, with amylase and lipase levels rising within hours of onset. These enzymes digest carbohydrates and fats, respectively, and their elevation confirms pancreatic injury, aiding diagnosis alongside clinical symptoms like abdominal pain.
Choice B reason: Decreased bilirubin is not typical in acute pancreatitis. Bilirubin may rise if pancreatitis causes biliary obstruction, but this is not a primary finding. The condition primarily affects pancreatic enzymes, not liver function markers like bilirubin, unless complications like gallstone pancreatitis or bile duct compression occur, which are secondary issues.
Choice C reason: Elevated hemoglobin is not expected in acute pancreatitis. Hemoglobin may decrease due to inflammation, bleeding, or fluid shifts causing hemodilution. Pancreatitis does not stimulate erythropoiesis or concentrate blood, so elevated hemoglobin is more likely in dehydration or other conditions, not a primary feature of pancreatic inflammation.
Choice D reason: Decreased calcium is common in acute pancreatitis due to fat necrosis and saponification, where calcium binds to fatty acids released from damaged pancreatic tissue. This reduces serum calcium levels, potentially causing hypocalcemia. Monitoring is critical, as low calcium can lead to neuromuscular irritability or cardiac complications in severe cases.
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