A nurse is caring for a client with diabetic ketoacidosis (DKA) who came in with a blood glucose of 790 mg/dL. The DKA treatment protocol has been implemented for at least 6 hours. The most recent finger stick blood glucose is 190 mg/dL. Which of the following nursing interventions will the nurse anticipate to do next?

Continue current isotonic fluids intravenously

Discontinue insulin infusion

Monitor blood glucose every 4 hours

Start dextrose 5% solution intravenously

Answer and Explanation

The Correct Answer is D

Choice A reason: Continuing isotonic fluids alone is not the next step when blood glucose drops to 190 mg/dL in DKA. Isotonic fluids (e.g., 0.9% saline) are used initially to restore volume, but as glucose nears 200 mg/dL, adding dextrose prevents hypoglycemia while insulin continues to resolve acidosis, making this choice less appropriate.

Choice B reason: Discontinuing insulin infusion is incorrect, as DKA requires continuous insulin to correct acidosis and ketosis, even after glucose normalizes. Insulin suppresses ketone production by inhibiting lipolysis and gluconeogenesis, driven by glucagon excess. Stopping insulin prematurely risks worsening acidosis, making this an unsafe intervention.

Choice C reason: Monitoring blood glucose every 4 hours is insufficient during active DKA treatment, where hourly checks are standard to titrate insulin and fluids. Glucose at 190 mg/dL requires adding dextrose to prevent hypoglycemia while continuing insulin, making frequent monitoring and intervention more critical than this choice suggests.

Choice D reason: Starting dextrose 5% solution intravenously is the correct next step when blood glucose reaches 190 mg/dL in DKA. This prevents hypoglycemia as insulin continues to correct acidosis and ketosis, maintaining glucose levels while addressing anion gap closure, driven by insulin’s role in suppressing ketone production and restoring metabolic balance.

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Correct Answer is C

Explanation

Choice A reason: Increased hunger is not associated with SIADH, which involves excessive antidiuretic hormone causing water retention. Hunger is more related to metabolic or hypothalamic disorders. SIADH affects fluid and electrolyte balance, primarily leading to hyponatremia, not appetite changes, making this choice incorrect.

Choice B reason: Hypernatremia is not expected in SIADH. Excessive antidiuretic hormone causes water retention, diluting serum sodium and leading to hyponatremia. Hypernatremia occurs in conditions like diabetes insipidus with water loss, not SIADH’s water excess, making this an incorrect manifestation.

Choice C reason: Hyponatremia is a hallmark of SIADH, as excessive antidiuretic hormone increases renal water reabsorption, diluting serum sodium (below 135 mEq/L). This can cause neurological symptoms like confusion, especially post-craniotomy, where brain injury may trigger ADH release, making this the expected finding.

Choice D reason: Weight loss is not typical in SIADH, which causes water retention, leading to weight gain from fluid accumulation. Weight loss occurs in conditions like diabetes insipidus with water loss, not SIADH’s fluid retention, making this an incorrect manifestation for the condition.

A. Initiate measures to cool the client B. Turn the client every 4 hr C. Place the client on aspiration precautions D. Check the client’s blood pressure every 2 hr

Correct Answer is C

Explanation

Choice A reason: Initiating cooling measures is inappropriate for myxedema coma, a hypothyroid crisis causing hypothermia due to low metabolic rate. Warming measures are needed to correct hypothermia, as cooling exacerbates the condition, making this an incorrect and potentially harmful intervention.

Choice B reason: Turning the client every 4 hours prevents pressure ulcers but is not the priority in myxedema coma. Aspiration risk from depressed consciousness and respiratory drive is more immediate, requiring precautions to protect the airway, making this a secondary intervention.

Choice C reason: Placing the client on aspiration precautions is critical in myxedema coma, as severe hypothyroidism causes depressed consciousness and respiratory drive, increasing aspiration risk. Precautions like elevating the head of the bed protect the airway, addressing the immediate life-threatening risk in this condition.

Choice D reason: Checking blood pressure every 2 hours is important but not the priority in myxedema coma. Hypotension occurs, but aspiration risk from altered mental status and respiratory depression poses a greater immediate threat, making aspiration precautions the primary intervention.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who had a craniotomy and has developed syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following manifestations should the nurse anticipate?

Correct Answer is C

Explanation

A nurse is caring for a client who is in a myxedema coma. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is assigned a client who is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) with a serum sodium level of 118 mEq/L. Which of the following interventions will the nurse anticipate for this client? (Select all that apply)

A nurse is caring for a client who has cirrhosis and a prothrombin time of 30 seconds (expected PT range: 11–12.5 seconds). Which of the following medications should the nurse plan to administer?

A nurse admits a client to the emergency department who reports nausea and vomiting that worsens when he lies down. Antacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see?

A nurse is caring for a client who has diabetes insipidus (DI) and is receiving vasopressin. The nurse should identify which of the following findings as an indication that the medication is effective?

A nurse is caring for a client on an insulin drip for their diabetic ketoacidosis (DKA). The provider ordered 0.1 unit/kg/hr. The client’s weight is 88 lbs. How many units of insulin will the nurse program the pump to infuse per hour? Round to the nearest tenth.

A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis. Which of the following information should the nurse include in the presentation?

A nurse is assessing a client who has hypothyroidism. Which of the following findings should the nurse expect?

A nurse is caring for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse implement to reduce the client’s ammonia levels?