A patient with diabetic ketoacidosis (DKA) has been receiving insulin for 6 hours. Laboratory finding are Na+ 131, K+ 3.7, CL- 102, HCO3 22, and glucose 170. Which action should the nurse take?
Give potassium intravenously.
Administer D5 NS with the insulin drip.
Administer 3% NS at 200ml/hr
Expect the insulin drip to be discontinued.
The Correct Answer is B
A. Give potassium intravenously. – The potassium level is 3.7 (within normal range 3.5–5.0), so potassium is not needed yet.
B. Administer D5 NS with the insulin drip. – Correct Answer. Once glucose drops to ≤200 mg/dL, dextrose is added to prevent hypoglycemia while continuing insulin to correct ketoacidosis.
C. Administer 3% NS at 200 mL/hr. – Hypertonic saline is used for severe hyponatremia, which is not the case here.
D. Expect the insulin drip to be discontinued. – The insulin drip is not discontinued until ketoacidosis has fully resolved (when HCO3 > 18, pH > 7.3, and anion gap normalizes).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Reflect on how she's feeling, and encourage her to express other fears that she has about his injury – Acknowledging emotions and encouraging open expression helps the mother process her grief and begin adjusting to the reality of the injury.
B. Explain that you aren't sure, but you will ask the physician to talk to her right away – Deferring to the physician misses an opportunity for emotional support.
C. Advise her that it isn’t in his best interest for her to be so upset, and explain the importance of moral support – This dismisses her emotions rather than addressing them.
D. Reassure her that given time and motivation he will return to normal function – Providing false reassurance is inappropriate, as a C5 spinal cord injury results in permanent loss of function.
Correct Answer is C
Explanation
A. 8 hr – Incorrect. RBC transfusions must not exceed 4 hours due to the risk of bacterial growth and hemolysis.
B. 6 hr – Incorrect. Blood products should be infused within a maximum of 4 hours to prevent complications.
C. 4 hr – Correct Answer. The maximum infusion time for packed RBCs is 4 hours to reduce the risk of bacterial contamination and infection.
D. 2 hr – Incorrect. While blood is often infused within 2 hours, the maximum safe limit is 4 hours.
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