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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale: this corresponds with 25 mg which is lower than the prescribed amount.

Choice B rationale: To answer this question, we need to use the formula: volume (mL) = dose (mg) / concentration (mg/mL). We plug in the given values: volume (mL) = 35 mg / 25 mg/mL. We simplify the fraction: volume (mL) = 7/5. We convert the fraction to a

decimal: volume (mL) = 1.4. Therefore, the nurse should administer 1.4 mL of promethazine.

Choice C rationale: this corresponds with 37.5 mg which is too high.

Choice D rationale: this corresponds with 17.5 mg which is too low.

A. Determine if blood is present in urine B. Perform a neurological assessment C. Administer IV normal saline D. Perform a 12-lead electrocardiogram

Correct Answer is C

Explanation

Choice A rationale: Although important to assess for potential kidney injury, addressing hypotension due to potential spinal shock takes priority.

Choice B rationale: Important for determining any neurological deficits, but addressing hypotension is the initial priority.

Choice C rationale: Hypotension indicates potential spinal shock or hemorrhagic shock, and fluid resuscitation is the immediate priority to stabilize the client's blood pressure.

Choice D rationale: While important for assessing cardiac status, addressing hypotension takes precedence to stabilize the client's condition.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The client is brought to the ER after falling off a roof and landing on his back. A T4 spinal fracture is diagnosed. The client's blood pressure is 74/40 mmHg, pulse is 55/min, and skin is pink and dry. What of the following nursing actions is a priority?

Correct Answer is C

Explanation

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