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: Sweaty palms may be related to various factors, including anxiety, physical activity, or environmental conditions. While it may warrant further assessment, it is not necessarily indicative of a nutritional issue in a professional dancer.
Choice B: Fatigue in a professional dancer can be a concerning issue and may indicate an underlying nutritional problem, such as inadequate calorie intake or nutrient deficiencies. Further assessment of the client's dietary habits and energy levels is warranted.
Choice C: Bunions are a foot deformity and are not directly related to nutritional assessment.
Choice D: Dry skin may be related to various factors, including environmental conditions and skin care practices. It may warrant assessment but is not necessarily indicative of a nutritional issue.
Correct Answer is B
Explanation
Choice A: This is important for the client's overall health but is not the most immediate priority in managing diabetes.
Choice B: The most important intervention for this client is to address lifestyle factors that contribute to diabetes and overall health. Weight loss and dietary changes are key components of managing type 2 diabetes. The client's weight is significantly above a healthy range, and losing 2 pounds (1 kg) per week is a reasonable and safe goal.
Choice C: Encouraging family members to be tested for diabetes is relevant but does not directly address the client's own management of the condition.
Choice D: Determining the client's feelings about the diagnosis is important for emotional support but does not directly address the client's physical health and diabetes management.
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