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 C
Explanation
C. An increase in uric acid levels (hyperuricemia) is a hallmark finding in acute gout. Elevated uric acid levels predispose to the formation and deposition of urate crystals in joints, leading to the inflammatory response seen in gout attacks.
A While CK levels can increase in conditions affecting muscles (like rhabdomyolysis), it is not specifically associated with acute gout.
C Uric acid levels are typically elevated during acute gout attacks. This is because gout results from the deposition of urate crystals in the joints due to elevated serum uric acid levels. Therefore, during an acute gout attack, uric acid levels in the blood are often higher than normal.
D. Chloride is an electrolyte and its levels can vary based on hydration status, acid-base balance, and kidney function. It is not directly associated with acute gout, so its levels would not necessarily increase in this condition.
Correct Answer is C
Explanation
C. Restlessness and agitation can be early signs of increased ICP. They result from the brain's attempt to compensate for the increasing pressure. Restlessness may indicate discomfort or confusion caused by cerebral edema or pressure on brain structures.
A Projectile vomiting can occur with increased ICP due to stimulation of the vomiting center in the brainstem as a response to pressure on the brain. It is a symptom that may indicate a more advanced increase in ICP rather than an early manifestation.
B. Papilledema refers to swelling of the optic disc due to increased intracranial pressure transmitting through the optic nerve sheath. It is typically a late manifestation of increased ICP rather than an early one. It requires time for pressure to build up and affect the optic nerve.
D. Decorticate posturing is a type of abnormal posture that can occur with severe brain injury or increased ICP. It involves flexion of the arms, wrists, and fingers with adduction of the upper extremities and extension of the lower extremities. This is typically a later sign of increased ICP
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