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 B
Explanation
Choice A rationale: Adenomas are benign tumors that originate from glandular tissue, such as the endometrium, the inner lining of the uterus.
Choice B rationale: Leiomyomas, also known as fibroids, are benign tumors that arise from the smooth muscle cells of the myometrium, the middle layer of the uterine wall. They are the most common type of uterine tumors, affecting up to 80% of women by age 50. They can cause symptoms such as heavy menstrual bleeding, pelvic pain, pressure, and infertility.
Choice C rationale: Endometriosis is a condition where endometrial tissue grows outside the uterus, causing inflammation and pain.
Choice D rationale: Adenomyosis is a condition where endometrial tissue invades the myometrium, causing enlargement and distortion of the uterus.
Correct Answer is A
Explanation
Choice A rationale: The Tensilon test involves injecting edrophonium, and in myasthenia gravis, temporary improvement in muscle strength confirms the diagnosis by demonstrating increased acetylcholine activity at the neuromuscular junction.
Choice B rationale: This describes the pathophysiology of myasthenia gravis but doesn’t directly confirm the diagnosis via the Tensilon test.
Choice C rationale: While this may be seen in myasthenia gravis, the Tensilon test specifically aims to observe improved muscle strength after administration.
Choice D rationale: While the presence of these antibodies is a characteristic of myasthenia gravis, the Tensilon test is used to assess the immediate response to the medication for diagnostic confirmation.
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