The nurse is caring for a client with diabetic ketoacidosis (DKA) receiving intravenous (IV) regular insulin. The most recent potassium was 2.9 mEq/L. The nurse should take which priority action:
Assess the client urine output (UOP)
Obtain a 12-lead electrocardiogram (ECG)
Notify the primary healthcare provider (PMHCP)
Stop the regular insulin infusion
The Correct Answer is C
Choice A rationale: Assessing the UOP is important, but not as urgent as correcting the potassium imbalance.
Choice B rationale: Obtaining a 12-lead ECG can help monitor the cardiac status, but it does not address the cause of the problem.
Choice C rationale: The PMHCP can order potassium replacement to prevent cardiac arrhythmias and other adverse effects of low potassium levels.
Choice D rationale: Stopping the regular insulin infusion can worsen the DKA and increase the risk of cerebral edema and coma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: Furosemide is a loop diuretic used to increase urine output by blocking the reabsorption of sodium and water. It's not typically associated with hyperkalemia. In fact, it's more common for loop diuretics like furosemide to cause hypokalemia (low potassium) due to increased urinary excretion of potassium.
Choice B rationale: Lovastatin is a statin used to lower cholesterol levels. It is not related to increased cholesterol. Additionally, there is no known direct interaction between lovastatin and furosemide. Furosemide is a diuretic, while selective serotonin reuptake inhibitors (SSRIs) are a class of antidepressants, and they do not typically interact in a way that requires discontinuation.
Choice C rationale: Duloxetine is an antidepressant (SNRI), and glipizide is an oral diabetes medication. There's no direct interaction between duloxetine and glipizide that would necessitate discontinuation.
Choice D rationale: Trimethoprim/sulfamethoxazole (Bactrim) is a sulfonamide antibiotic, and glipizide belongs to the sulfonylurea class of medications. Both drugs contain sulfur groups in their chemical structures, and there is a possibility of cross-reactivity or drug interaction. This interaction can potentially reduce the effectiveness of glipizide, leading to compromised blood sugar control. Additionally, sulfonamide antibiotics like trimethoprim/sulfamethoxazole can cause adverse reactions, including skin rashes or hypersensitivity reactions, particularly in individuals sensitive to sulfa medications.
Correct Answer is B
Explanation
Choice A rationale: This is a positive Trousseau's sign, which indicates hypocalcemia or tetany. It is not related to meningitis or meningeal irritation.
Choice B rationale: Kernig's sign is indicated when there is resistance and pain with knee extension and hip flexion, suggesting meningeal irritation.
Choice C rationale: This is a positive Homan's sign, which indicates deep vein thrombosis or phlebitis. It is not related to meningitis or meningeal irritation.
Choice D rationale: This is a sign of nuchal rigidity, which indicates meningeal irritation, but it is not specific to Kernig's sign. Nuchal rigidity can also be caused by other conditions such as cervical arthritis or muscle spasm.

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