A client is admitted with diabetic ketoacidosis (DKA) and is receiving an IV infusion of 0.9% sodium chloride and insulin. Two hours later, the client's serum laboratory results show a decrease in the serum blood glucose from 580 to 430 mg/dL (32.2 to 23.86 mmol/L). It is most
important for the nurse to monitor which additional laboratory result?
Reference Range
Serum potassium.
Urine ketones.
Serum sodium.
Blood urea nitrogen (BUN).
The Correct Answer is A
A. Serum potassium. Insulin therapy causes potassium to move into cells, which can lead to hypokalemia. Monitoring serum potassium is critical because significant drops can lead to cardiac arrhythmias and other complications.
B. Urine ketones. While monitoring ketones is important for assessing the resolution of DKA, it is not as immediately critical as monitoring potassium levels.
C. Serum sodium. Sodium levels are important but typically do not change as rapidly as potassium levels during DKA treatment.
D. Blood urea nitrogen (BUN). BUN levels provide information about kidney function and hydration status but are less immediately critical than potassium levels in the context of insulin therapy for DKA.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Instruct the family about withdrawal symptoms. While educating the family about withdrawal symptoms is important for support and understanding, it is not the best initial action when the
client is experiencing severe agitation and tremors. Safety measures should be prioritized.
B. Initiate seizure precautions. Severe agitation and tremors can be signs of benzodiazepine withdrawal, which may progress to seizures. Initiating seizure precautions, such as ensuring a
safe environment, padding side rails, and having emergency medications and equipment readily available, is the priority to prevent injury.
C. Obtain a serum drug screen. While obtaining a serum drug screen may be necessary to confirm benzodiazepine withdrawal, it is not the immediate action needed to address the client's current symptoms and prevent potential harm.
D. Administer naloxone per PRN protocol. Naloxone is an opioid antagonist used to reverse opioid overdose and is not indicated for benzodiazepine withdrawal. Administering naloxone would not be appropriate or effective in this situation.
Correct Answer is ["A","C","F","G"]
Explanation
A. Humidifier bottle
Rationale: A humidifier bottle is often used with oxygen therapy to add moisture to the oxygen, preventing dryness of the nasal passages and throat. It is important for patient comfort, especially when oxygen is administered at higher flow rates for prolonged periods.
B. Lamb's wool
Rationale: Lamb's wool is not needed for starting oxygen therapy. It is typically used to provide padding and comfort in other situations, such as preventing pressure sores, but it has no role in the administration of oxygen.
C. Flowmeter
Rationale: A flowmeter is necessary to regulate the flow rate of oxygen. It ensures that the client receives the prescribed amount of oxygen (3 L/minute in this case), making it an essential component for administering oxygen therapy.
D. Tape
Rationale: Tape is not required for administering oxygen via a nasal cannula. It might be used to secure tubing in other contexts, but it is not specifically needed for starting oxygen therapy. The nasal cannula usually stays in place without the need for tape.
E. Suction cannister
Rationale: A suction canister is used in suctioning procedures to collect secretions and is not needed for starting oxygen therapy. It is relevant for managing airway secretions but unrelated to the administration of oxygen.
F. Nasal cannula
Rationale: A nasal cannula is the device through which oxygen is delivered to the client. It is specifically mentioned in the order and is essential for administering the oxygen.
G. Sterile water
Rationale: Sterile water is used to fill the humidifier bottle to provide humidified oxygen. This helps to prevent the drying effects of oxygen therapy on the mucous membranes, enhancing patient comfort.
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