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 B
Explanation
Choice A: Pretzels are a carbohydrate-rich snack with a high glycemic index, which can lead to spikes in blood glucose levels. Choosing pretzels does not indicate a good understanding of the diet teaching to avoid refined sugar and carbohydrates.
Choice B: Avocado is a healthy choice for a client with Type 2 diabetes mellitus (DM) who wants to avoid refined sugar and carbohydrates. Avocado is a source of healthy fats, fiber, and other nutrients and has a low glycemic index.
Choice C: Potatoes are starchy vegetables that are high in carbohydrates, particularly when prepared in ways like mashed potatoes or fries. Choosing potatoes does not align with the goal of avoiding refined sugar and carbohydrates.
Choice D: Grapes are a fruit that contains natural sugars, and consuming them can affect blood glucose levels. Choosing grapes does not demonstrate an understanding of the need to avoid refined sugar and carbohydrates.
Correct Answer is B
Explanation
Choice A: Comprehension of simple commands is an earlier developmental stage and not directly related to the infant's ability to search for a fallen toy.
Choice B: Exploration beyond caregiver presence is a key characteristic of the sensorimotor stage in Piaget's theory. During this stage, infants develop object permanence and begin to explore their environment independently.
Choice C: Visible or audible separation anxiety is common during the early stages of infancy and is not specific to the sensorimotor stage.
Choice D: The ability to place objects in a container is more related to later developmental stages when fine motor skills are more developed.
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