Exhibits
Which are three goals of therapy for this client?
Promote oxygenation to tissues
Reverse dehydration
Replace insulin
Correct electrolytes that are out of normal range
Provide respiratory support F Prevent hyperventilation
Correct Answer : B,C,D
A. Promote oxygenation to tissues. Oxygenation is not a primary goal in DKA management unless there is a coexisting condition causing hypoxia. DKA primarily leads to metabolic acidosis and dehydration rather than respiratory failure, and oxygenation is typically maintained unless complications such as pneumonia or severe shock develop.
B. Reverse dehydration. Severe dehydration occurs in DKA due to osmotic diuresis caused by hyperglycemia. The priority is to restore intravascular volume with isotonic IV fluids such as 0.9% normal saline to improve circulation, support kidney function, and prevent shock. Fluid replacement is essential for stabilizing blood pressure and promoting glucose clearance.
C. Replace insulin. The lack of insulin is the primary cause of DKA, leading to unchecked lipolysis and ketone production. IV insulin therapy is necessary to suppress ketogenesis, lower blood glucose levels, and allow cells to use glucose for energy. Insulin must be administered cautiously with continuous monitoring to prevent hypoglycemia and electrolyte imbalances.
D. Correct electrolytes that are out of normal range. Electrolyte imbalances, particularly potassium depletion, are common in DKA due to osmotic losses and shifting caused by insulin therapy. Potassium replacement is required even if levels appear normal initially, as insulin will drive potassium into cells, leading to hypokalemia. Sodium and bicarbonate levels should also be monitored and corrected as needed.
E. Provide respiratory support. Respiratory support is not typically required unless the client experiences severe respiratory distress or altered mental status. Kussmaul respirations are a natural compensatory mechanism that helps the body exhale CO₂ and correct acidosis. Supplemental oxygen is only necessary if there is an underlying pulmonary condition or respiratory failure.
F. Prevent hyperventilation. Hyperventilation in the form of Kussmaul respirations is the body's way of compensating for metabolic acidosis. It should not be suppressed, as it plays a crucial role in reducing acid buildup. Treating the underlying cause of DKA with fluids, insulin, and electrolyte replacement will allow respiratory function to normalize.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Observe vital signs sequences as a way of assessing for Cushing's triad. Cushing’s triad (hypertension with widened pulse pressure, bradycardia, and irregular respirations) is a late sign of increased intracranial pressure (ICP). While monitoring for it is important, early recognition and direct ICP monitoring are more effective in preventing deterioration.
B. Evaluate hourly urinary output. Mannitol is an osmotic diuretic that can cause significant diuresis, requiring close monitoring of urine output to prevent dehydration and electrolyte imbalances. However, assessing ICP is the priority because increased ICP can cause brain herniation, which is life-threatening.
C. Monitor arterial blood pressure. Dopamine is a vasopressor used to maintain cerebral perfusion pressure (CPP), which is crucial in head injury management. While blood pressure monitoring is essential, directly assessing ICP ensures that treatment is effective in preventing secondary brain injury.
D. Assess intracranial pressure following intracranial transducer placement. The highest priority is monitoring ICP immediately after placement to detect dangerous elevations that could lead to herniation. The intraventricular catheter provides real-time pressure readings, guiding interventions like mannitol administration and blood pressure control to optimize cerebral perfusion and prevent worsening neurological damage.
Correct Answer is A
Explanation
A. Document that the client is experiencing a paced rhythm. A pacemaker spike before each QRS complex indicates that the pacemaker is functioning properly and triggering ventricular depolarization as intended. Since the client is 24 hours postoperative from a pacemaker insertion, this is an expected finding and should be documented accordingly.
B. Reposition the ECG leads and obtain another recording. If the ECG showed artifact, lead displacement, or interference, repositioning the leads might be appropriate. However, the presence of consistent pacemaker spikes before each QRS complex suggests proper pacemaker function rather than a lead issue.
C. Assess the client for symptoms of decreased cardiac output. A paced rhythm is expected after pacemaker insertion and does not necessarily indicate hemodynamic instability. While assessment is always important, there is no indication that the client is experiencing decreased cardiac output symptoms such as hypotension, dizziness, or altered mental status.
D. Notify the healthcare provider (HCP) of the telemetry recording. Routine paced rhythms do not require immediate provider notification unless there are malfunctions such as failure to capture, failure to sense, or failure to pace. Since the pacemaker is functioning appropriately, notifying the HCP is unnecessary.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.