The nurse is caring for a client admitted with diabetic ketoacidosis (DKA). Which intervention is most important for the nurse to include in the client's plan of care?
Strict intake and output.
Maintain a large bore IV.
Keep NPO except for ice.
Monitor laboratory values
The Correct Answer is D
Choice A: Strict intake and output monitoring is important in the care of clients with DKA, but it is not the most critical intervention among the choices provided.
Choice B: Maintaining a large bore intravenous (IV) is important for providing the necessary fluids and medications in DKA treatment, but it is not the highest priority.
Choice C: Keeping the client NPO except for ice may be part of the initial management of DKA to address fluid and electrolyte imbalances, but it is not the most important intervention in the client's overall plan of care.
Choice D: Monitoring laboratory values is the most important intervention for a client with diabetic ketoacidosis (DKA). Regular assessment of blood glucose levels, electrolytes (e.g., potassium, sodium), and arterial blood gases (ABGs) is crucial for guiding treatment and ensuring that DKA is resolving. Adjustments to insulin and fluids are based on these laboratory values to prevent complications such as cerebral edema or cardiac arrhythmias.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: When a reflex response is not elicited, it is important to proceed with testing other reflexes later in the exam to assess the overall neurological status. A single absence of a reflex may not be indicative of a problem, so further assessment is needed.
Choice B: Distracting the client by instructing him to pull on his fingers is not an appropriate action when assessing reflexes.
Choice C: Instructing the client to see a neurologist as soon as possible based solely on the absence of one reflex would be premature. Further assessment is needed to determine the significance.
Choice D: Recording the patellar reflex as a zero without further assessment would not provide a comprehensive evaluation of the client's reflexes.
Correct Answer is D
Explanation
Choice A rationale: Referring the client to a dietitian for nutrition education is a proactive step. Dietitians can provide personalized guidance and address the client's dietary concerns and preferences. However, this alone may not be sufficient if the client is strongly resistant to dietary changes.
Choice B rationale: Providing pamphlets about heart-healthy diet selections is informative but may not effectively address the client's resistance to dietary changes. The client's reluctance needs to be explored and addressed through a more interactive approach.
Choice C rationale: While exercise is important for heart health, the primary concern here is the client's elevated cholesterol levels, which are significantly impacted by dietary choices. Suggesting exercise alone may not adequately address the issue at hand.
Choice D rationale: Discussing the client's concerns about the change in diet is the most appropriate initial action. It allows the nurse to understand the client's perspective, identify barriers to compliance, and work collaboratively with the client to develop a plan that considers his preferences and challenges. This approach is more likely to lead to a successful change in diet and lifestyle compared to simply providing information or referrals.
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