Exhibits
Which of the following 3 provider prescriptions does the nurse anticipate?
Regular insulin 20 units subcutaneously
Potassium chloride 20 mEq/L intravenous PRN potassium less than 5.0 mEq/L
Initiate cardiac monitoring
0.9% sodium chloride at 15 ml/kg/hr for 1 hr and then reduce to 10 ml/kg/hr
Regular insulin continuous intravenous infusion, titrate per diabetic ketoacidosis (DKA) protocol once potassium is greater than 3.3 mEq/L
Dextrose 5% in water (DSW) intravenous at 5 ml/kg/hr for 4 hr
Blood glucose checks every 4 hr
Insert indwelling urinary catheter
Correct Answer : B,D,E
. Potassium chloride 20 mEq/L intravenous PRN potassium less than 5.0 mEq/L
The client's potassium level is slightly elevated at 5.5 mEq/L. Potassium replacement may be necessary if the level drops below 5.0 mEq/L, which is within the anticipated range for the nurse's actions.
D.0.9% sodium chloride at 15 ml/kg/hr for 1 hr and then reduce to 10 ml/kg/hr
This prescription addresses the need for fluid resuscitation to correct dehydration and electrolyte imbalances often seen in DKA. The client's initial blood pressure of 96/65 mm Hg suggests some degree of dehydration, further supporting the use of isotonic saline.
E.Regular insulin continuous infusion, titrate per diabetic ketoacidosis (DKA) protocol once potassium is greater than 3.3 mEq/L
This prescription aligns with the client's presentation of severe hyperglycemia (468 mg/dL) and acidosis (pH 7.30), indicating diabetic ketoacidosis (DKA). Insulin infusion is crucial for lowering blood glucose levels and correcting acidosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. When using a quad cane, the client should always maintain two points of support on the floor: the cane and either the affected (left) or unaffected (right) leg. This ensures stability and support while walking.
A When using a quad cane, the client should advance their weaker (left) foot and then the stronger (right) foot. This allows the cane to provide support on the weaker side.
C. This action is correct for a client with left-sided hemiparesis. The quad cane should be held on the stronger side (right hand) to provide support for the weaker side (left leg).
D. This statement is unclear in terms of the context provided. However, typically when using a quad cane, the cane is moved forward a comfortable distance with each step to provide continuous support and balance. The exact distance may vary depending on the client's stride length and comfort.
Correct Answer is C
Explanation
C. Cloudy effluent is one of the earliest and most specific signs of peritonitis. It warrants immediate evaluation and diagnostic testing to confirm the diagnosis and initiate appropriate treatment.
A Generalized abdominal pain is a common symptom of peritonitis but may not be the earliest indication.
B. Tachycardia (increased heart rate) can occur in response to infection or inflammation, including peritonitis. It is a systemic response rather than a localized symptom.
D. Fever can also be associated with peritonitis but may appear later and is not as specific early indicators
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