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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Apply high-flow oxygen by face mask. The client is in respiratory distress with absent breath sounds over the left lung field, which is highly suggestive of a pneumothorax or hemothorax. High-flow oxygen helps improve oxygenation while preparing for definitive intervention. In cases of tension pneumothorax, oxygen can help reduce hypoxia until a chest tube or needle decompression is performed.
B. Obtain a chest tube insertion kit. Absent breath sounds on one side following chest trauma strongly suggest a pneumothorax or hemothorax, requiring immediate chest tube placement to re-expand the lung and restore normal ventilation. The nurse should ensure that the equipment for thoracostomy (chest tube insertion) is readily available for the healthcare provider.
C. Withhold narcotic pain medication. Pain control is important in trauma patients, as uncontrolled pain can lead to shallow breathing, atelectasis, and respiratory complications. Narcotics should be used cautiously in clients with respiratory distress, but they are not contraindicated if given at appropriate doses with close monitoring.
D. Elevate the head of the bed 45 degrees. Clients with respiratory distress should be positioned with the head of the bed elevated to improve lung expansion. However, in a suspected pneumothorax, the priority is oxygenation and chest tube insertion. If there is hemodynamic instability, the client may require a flat or semi-Fowler’s position instead.
E. Place client in Trendelenburg position. The Trendelenburg position (head down, feet up) is not appropriate in chest trauma patients. This position can increase intra-abdominal pressure, worsen breathing difficulty, and impair lung expansion. It is typically avoided in clients with respiratory distress or suspected pneumothorax.

A. Document that the client is experiencing a paced rhythm. B. Reposition the ECG leads and obtain another recording. C. Assess the client for symptoms of decreased cardiac output. D. Notify the healthcare provider (HCP) of the telemetry recording.

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.

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Exhibits Which are three goals of therapy for this client?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse assesses the telemetry monitor of a client who is 24 hours postoperative from having a permanent pacemaker insertion. The nurse observes that a pacemaker spike is present before each QRS complex in lead II of the electrocardiogram (ECG). Which intervention should the nurse implement?

Correct Answer is A

Explanation

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Exhibits

Which are three goals of therapy for this client?