The client is admitted to the ICU diagnoses with DKA. Which interventions should the nurse implement? (Select the 4 correct answers).(Select All that Apply.)
Push IV potassium
Administer intravenous potassium
Assess fluid volume status
Check for urinary ketones
Maintain adequate ventilation
Correct Answer : B,C,D,E
A. Push IV potassium: Potassium should be administered slowly and with caution, as administering potassium too rapidly can cause cardiac arrhythmias. Potassium should only be given according to specific protocols and after monitoring serum potassium levels.
B. Administer intravenous potassium: In diabetic ketoacidosis (DKA), potassium levels often decrease due to insulin therapy, which shifts potassium into cells. Intravenous potassium is often required to replace lost potassium and prevent dangerous complications.
C. Assess fluid volume status: In DKA, the client experiences significant fluid loss due to polyuria (frequent urination) and dehydration. It is important to closely monitor the client’s fluid volume status and correct it with intravenous fluids, typically normal saline.
D. Check for urinary ketones: Urinary ketones are a key marker in diagnosing DKA. The nurse should monitor for the presence of ketones in the urine as it helps assess the degree of ketosis and the effectiveness of treatment.
E. Maintain adequate ventilation: In DKA, respiratory compensation (such as Kussmaul breathing) is common as the body attempts to correct acidosis. Adequate ventilation should be ensured to support the respiratory system and correct the metabolic acidosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["33"]
Explanation
Calculation:
- Convert the infusion rate from milliliters per hour (mL/hr) to milliliters per minute (mL/min).
Infusion rate in mL/min = 200 mL/hr / 60 min/hr
= 3.333... mL/min.
Tubing drop factor = 10 gtt/mL.
- Calculate the flow rate in drops per minute (gtt/min).
Flow rate (gtt/min) = Infusion rate (mL/min) × Tubing drop factor (gtt/mL)
= 3.333 mL/min × 10 gtt/mL
= 33.333 gtt/min.
- Round the answer to the nearest whole number.
= 33 gtt/min.
Correct Answer is B
Explanation
A. Reduce serum lipid levels: While managing lipid levels is important for clients with diabetes, it is not the primary goal of medical nutrition therapy (MNT). The main focus is on blood glucose control rather than just lipid management.
B. Maintain as near-normal a blood glucose level as possible: The primary goal of MNT for clients with diabetes mellitus is to achieve and maintain near-normal blood glucose levels to prevent complications such as retinopathy, neuropathy, and cardiovascular disease.
C. Improve health through optimal nutrition: While optimal nutrition is important for overall health, the main objective of MNT in diabetes is focused on blood glucose control. Proper nutrition contributes to overall health, but it is not the sole goal.
D. Wean insulin-dependent clients with diabetes from insulin through diet control: While diet control can help manage blood glucose, it is unlikely to completely eliminate the need for insulin in insulin-dependent clients with type 1 diabetes.
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