A patient with diabetic ketoacidosis has the following laboratory test results; glucose 120; pH7.31; PCO2 33; serum potassium 5.3; urine ketones positive +3. Which should the nurse anticipate starting?
regular insulin and normal saline
5% Dextrose
Regular insulin and 5% dextrose
Normal Saline
The Correct Answer is A
Rationale:
A. regular insulin and normal saline: In diabetic ketoacidosis, the priority is fluid resuscitation with isotonic saline to correct dehydration and restore perfusion. Regular insulin is then started to reduce blood glucose and stop ketone production.
B. 5% Dextrose: Dextrose is not given initially because the patient’s blood glucose is still elevated in DKA. It is introduced later in therapy once glucose levels fall to around 250 mg/dL, to prevent hypoglycemia while continuing insulin therapy.
C. Regular insulin and 5% dextrose: Insulin is needed, but dextrose would not be appropriate at this stage because glucose is already significantly elevated. Giving dextrose too early would worsen hyperglycemia and delay correction of ketoacidosis.
D. Normal Saline: Normal saline alone helps correct dehydration but does not address the underlying problem of insulin deficiency. Without insulin therapy, ketosis and acidosis would persist despite fluid replacement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Malignant hypertension: While clients with DKA may have stress-related elevations in blood pressure, malignant hypertension is not a characteristic manifestation. DKA primarily presents with hyperglycemia, dehydration, and metabolic acidosis rather than extreme blood pressure elevation.
B. Cheyne-Stokes breathing: Cheyne-Stokes respirations are typically associated with severe brain injury, heart failure, or central nervous system disorders. In DKA, clients exhibit Kussmaul respirations, which are deep and rapid, as a compensatory mechanism for metabolic acidosis.
C. Acetone odor to breath: The presence of acetone or fruity-smelling breath results from ketone accumulation due to fat breakdown in the absence of sufficient insulin. This is a classic sign of diabetic ketoacidosis and reflects ongoing ketosis and metabolic derangement.
D. Blood glucose level below 40 mg/dL: DKA is characterized by significant hyperglycemia, typically above 250 mg/dL. Hypoglycemia is not expected; instead, elevated blood glucose contributes to osmotic diuresis, dehydration, and electrolyte imbalances.
Correct Answer is A
Explanation
Rationale:
A. Check your urine for ketones when blood glucose levels are greater than 240 mg/dL: Monitoring for ketones when hyperglycemia occurs helps detect early diabetic ketoacidosis. Identifying ketones allows for timely medical intervention and prevents worsening acidosis and dehydration.
B. Withhold your usual daily dose of insulin: Insulin should never be withheld during illness because the body typically needs more insulin to counteract stress hormones. Stopping insulin increases the risk of severe hyperglycemia and development of DKA.
C. Test your blood glucose level every 8 hours: During illness, blood glucose levels can fluctuate rapidly, requiring monitoring every 2–4 hours. Testing only every 8 hours would delay recognition and treatment of dangerously high glucose levels.
D. Drink 240 to 360 milliliters of calorie-free liquids every 8 hours: Fluid intake is important to prevent dehydration, but the recommended frequency is every hour rather than every 8 hours. Frequent fluids help maintain hydration and reduce ketone concentration in the urine.
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