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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A: Nasogastric tube insertion may be indicated in the management of a client with peptic ulcer disease (PUD) to assess bleeding, relieve gastric distention, or administer medications. However, in this scenario, the client's presentation with sudden severe upper abdominal pain, a tender and rigid abdomen, hypotension, and tachycardia suggests a potentially life-threatening condition that requires immediate intervention beyond nasogastric tube insertion.

Choice B: Iced saline lavage is not a standard procedure for managing peptic ulcer disease (PUD) or its complications. It is not the immediate intervention required for the client's presentation.

Choice C: Administration of pantoprazole (Protonix) IV, a proton pump inhibitor, is a relevant intervention for managing peptic ulcer disease (PUD), but it may not be the most immediate action needed for a client with sudden severe abdominal pain, hypotension, and tachycardia. More urgent interventions are required.

Choice D: Emergency abdominal surgery is the most appropriate and immediate intervention for a client with sudden severe upper abdominal pain, a tender and rigid abdomen, hypotension, and tachycardia. These signs and symptoms may indicate a perforated peptic ulcer, which is a surgical emergency requiring prompt exploration and repair of the perforation to prevent peritonitis and sepsis.

A. Broccoli. B. Milk shake. C. Garden salad. D. Coffee.

Correct Answer is B

Explanation

Choice A: Broccoli is not typically restricted before a gallbladder ultrasound.

Choice B: Instructing the client to avoid consuming a milkshake the night before the test is important because a fatty meal can affect gallbladder contraction and visualization during the ultrasound.

Choice C: A garden salad is not typically restricted before a gallbladder ultrasound.

Choice D: Coffee is not typically restricted before a gallbladder ultrasound.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The nurse is preparing a client for ultrasonography of the gallbladder. What should the nurse instruct the client to avoid consuming the night before the test?

Correct Answer is B

Explanation

After receiving morning report about four clients, which client should the nurse attend to first?

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