Ten minutes after initiating an intravenous antibiotic, the client complains of shortness of breath, itching, and difficulty swallowing. What is the nurse's initial action?

Prepare to administer prescribed epinephrine

Assess the client's apical pulse and blood pressure

Stop infusing the client's intravenous antibiotic

Administer 4 liters of oxygen via nasal cannula

Answer and Explanation

The Correct Answer is C

A.   While epinephrine is crucial in cases of anaphylaxis, it should not be the first action taken. The immediate priority is to stop the offending medication.
B.   While assessing vital signs is important, it is not the first action. The primary concern is to halt the exposure to the potential allergen.
C.   The first action in this situation should be to immediately stop the infusion of the antibiotic. This prevents further exposure to the allergen and is critical to managing the potential anaphylactic reaction.

D.   While providing oxygen may be necessary later if the client is hypoxic, the immediate priority is to stop the infusion of the antibiotic first. Administering oxygen is important but comes after halting the offending agent.

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Correct Answer is ["A","C","E"]

Explanation

A. Lethargy can occur in DKA due to the effects of hyperglycemia, acidosis, and dehydration. Even if the client is oriented, confusion about the reason for care suggests an altered mental state, which can be common in DKA.
B. This ABG indicates alkalosis (pH > 7.45), which is not typical for DKA. In DKA, we would expect a lower pH (acidosis). This set of values does not align with the expected clinical picture of DKA.
C. This ABG shows a pH of 7.31, indicating acidosis. The low HCO3 (17) supports metabolic acidosis, which is characteristic of DKA. This finding is consistent with the expected laboratory results in a patient experiencing DKA.
D. A heart rate of 52 (bradycardia) is not a common finding in DKA. In fact, tachycardia (elevated heart rate) is typically observed due to dehydration and compensatory mechanisms. Bradycardia would not be expected in this context.
E. A respiratory rate of 31, particularly if deep (known as Kussmaul respirations), is a classic sign of metabolic acidosis, including DKA. Kussmaul respirations are the body’s attempt to compensate for acidosis by increasing carbon dioxide elimination.

A. an upper urinary tract infection B. decreased caloric intake C. aerobic exercise D. clogged tubing of a subcutaneous insulin pump E. not taking sufficient insulin

Correct Answer is ["A","B","D","E"]

Explanation

A. Infections, including urinary tract infections, can increase insulin resistance and elevate blood glucose levels, potentially leading to DKA. The stress response from infection can also increase cortisol levels, further contributing to hyperglycemia.
B. Decreased caloric intake can lead to inadequate insulin levels relative to the body’s needs. In Type 1 diabetes, if insulin is not sufficient to metabolize glucose (due to low intake or other reasons), the body may resort to fat metabolism, leading to the production of ketones and the development of DKA.
C. While exercise can affect blood glucose levels, it typically lowers them and is not a direct cause of DKA. In fact, moderate aerobic exercise is usually encouraged for managing diabetes. However, if blood glucose levels are already high before exercise, it may exacerbate the situation, but aerobic exercise itself is not a cause of DKA.
D. Clogged tubing can prevent insulin delivery, leading to insufficient insulin levels. This lack of insulin can result in elevated blood glucose levels and, ultimately, the risk of DKA if not addressed.
E. Not taking enough insulin is a primary cause of DKA in Type 1 diabetes. Without adequate insulin, the body cannot utilize glucose properly, leading to increased fat metabolism and the production of ketones, which can cause DKA.

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Ten minutes after initiating an intravenous antibiotic, the client complains of shortness of breath, itching, and difficulty swallowing. What is the nurse's initial action?

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Naxlex Comprehensive Predictor Exams

What clinical manifestation(s) should the nurse expect in a client with uncontrolled diabetes mellitus and ketoacidosis? (SELECT ALL THAT APPLY)

Correct Answer is ["A","C","E"]

Explanation

The nurse is teaching an adult client with Type 1 diabetes that causes for the development of diabetic ketoacidosis (DKA) are (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","D","E"]

Explanation

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