The nurse is preparing to start an IV infusion of 1,000 mL of 0.9% sodium chloride with 30 mEq of potassium chloride for a client with diabetic ketoacidosis (DKA). Before implementing the prescription, which assessment finding is most important for the nurse to obtain?

Breath sounds.

Blood pressure.

Skin turgor.

Urinary output.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Breath sounds: Lung assessment is important during fluid resuscitation to monitor for fluid overload, especially in older adults or those with cardiac compromise. However, breath sounds do not determine whether potassium administration is safe. Potassium-related complications are not identified through respiratory assessment.

B. Blood pressure: Blood pressure reflects volume status and response to fluid therapy in DKA. Although hypotension supports the need for isotonic fluids, it does not assess renal ability to excrete potassium. Potassium administration decisions must be based on kidney function rather than hemodynamics alone.

C. Skin turgor: Skin turgor provides information about dehydration, which is common in DKA due to osmotic diuresis. While useful for overall assessment, it does not indicate renal perfusion or potassium excretion capacity. It is not sufficient to guide safe potassium replacement.

D. Urinary output: Adequate urine output confirms renal perfusion and the ability to excrete potassium. Potassium chloride must not be administered unless urine output is established, as impaired excretion can lead to life-threatening hyperkalemia. This assessment is critical before initiating potassium-containing IV fluids.

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Correct Answer is D

Explanation

Rationale:

A. Place bed in the reverse Trendelenburg position: This position does not specifically relieve pancreatic pain and may increase discomfort by altering abdominal organ positioning without supporting the client’s preferred posture.

B. Raise the head of the bed to a 90 degree angle: Upright positioning alone may not provide adequate support or comfort for the client who finds pain relief by leaning forward and flexing the trunk.

C. Encourage bed rest until analgesic takes effect: Pancreatic pain is often severe and position-dependent; forcing bed rest ignores an effective nonpharmacologic pain-relief strategy and may increase distress.

D. Provide a bedside table for client to lean across: Leaning forward reduces tension on the inflamed pancreas and decreases pain. Supporting this position enhances comfort and complements analgesic therapy.

A. Teach the client how to count carbohydrates B. Decrease the insulin IV infusion to 0.05 units/kg/hr C. Draw electrolyte levels D. Decrease the frequency of blood glucose tests E. Start the client on a regular diet F. Stop the insulin infusion G. Change the IV fluids to 0.45% sodium chloride with 5% dextrose

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"B"},"G":{"answers":"A"}}

Explanation

Rationale:

• Decrease the insulin IV infusion to 0.05 units/kg/hr: The client’s blood glucose levels are steadily decreasing, indicating that the insulin infusion is effective. In HHS, insulin rates are reduced once glucose levels approach the target range to prevent overly rapid declines that can increase the risk of cerebral edema and hypoglycemia. Careful titration supports safe glucose correction.

• Draw electrolyte levels: HHS causes significant osmotic diuresis, leading to electrolyte imbalances, particularly potassium shifts once insulin therapy is initiated. Frequent electrolyte monitoring is necessary to detect and correct abnormalities early and prevent cardiac and neuromuscular complications.

• Change the IV fluids to 0.45% sodium chloride with 5% dextrose: As blood glucose approaches 250–300 mg/dL, dextrose-containing fluids are added to prevent hypoglycemia while allowing continued insulin administration. Hypotonic saline supports ongoing rehydration while avoiding rapid osmolar shifts that could worsen neurologic status.

• Teach the client how to count carbohydrates: Diabetes self-management education is essential but is not a priority during the acute management of HHS. The client is still critically ill and requires stabilization before education can be effective and safely implemented.

• Decrease the frequency of blood glucose tests: Hourly blood glucose monitoring is essential during IV insulin therapy to guide titration and prevent hypoglycemia. Reducing monitoring frequency could delay detection of dangerous glucose changes during this critical phase.

• Start the client on a regular diet: Clients with HHS are typically kept NPO or on limited intake until metabolic stability is achieved. Starting a regular diet prematurely can worsen hyperglycemia and complicate insulin and fluid management.

• Stop the insulin infusion: Insulin infusion must be continued until hyperosmolarity resolves and blood glucose is consistently controlled. Stopping insulin too early can lead to rebound hyperglycemia and delay resolution of HHS.

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The nurse is preparing to start an IV infusion of 1,000 mL of 0.9% sodium chloride with 30 mEq of potassium chloride for a client with diabetic ketoacidosis (DKA). Before implementing the prescription, which assessment finding is most important for the nurse to obtain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with pancreatitis reports severe epigastric pain. After administering a narcotic analgesic, the client insists on sitting up and leaning forward. Which action should the nurse implement?

Correct Answer is D

Explanation

Patient Data Click to mark whether the nursing action is indicated, contraindicated, or non-urgent. Each row must have one option selected.

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"B"},"G":{"answers":"A"}}

Explanation

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