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).

Answer and Explanation

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.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale for A: Redressing the abdominal incision is crucial as the dressing is no longer occlusive, which could lead to infection. An intact dressing also prevents the client from picking at the site, which could cause further harm or delay healing.
Rationale for B: Leaving the lights on might help with visual perception for a client with dementia, but it does not directly address the immediate risk of infection or the client's interference with the dressing.
Rationale for C: Applying restraints could be considered for a client who is at risk of harming themselves, but this should be a last resort after other interventions have been tried due to the potential for physical and psychological harm.
Rationale for D: Replacing the IV site with a smaller gauge is not indicated by the pink insertion site alone and does not address the client's confusion or behavior towards the dressing.

A. Left 5th intercostal space midclavicular line B. Right carotid area C. Over the brachial artery D. Over the sternum

Correct Answer is C

Explanation

A. Left 5th intercostal space midclavicular line: Palpating the left 5th intercostal space midclavicular line is not appropriate for assessing pulse in an unresponsive infant. This location is typically used for cardiac auscultation and not for pulse assessment.
B. Right carotid area: Palpating the carotid artery is not recommended in infants due to the risk of causing injury to the delicate structures of the neck, including the
airway and blood vessels.

C. Over the brachial artery: The brachial artery is the preferred site for assessing pulse in infants. It is located in the inner aspect of the upper arm and can be easily palpated. In an unresponsive infant, the brachial pulse should be assessed before
initiating CPR.

D. Over the sternum: Palpating over the sternum is not an appropriate site for pulse assessment in infants. The sternum is a bone and does not contain any major arteries suitable for pulse palpation.

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

An infant is unresponsive and gasping for breath. Prior to starting CPR, which site should the nurse palpate for a pulse?

Correct Answer is C

Explanation

Which action should the school nurse implement to provide secondary prevention for school- aged children?

To auscultate for a carotid bruit, the nurse places the stethoscope at what location (Select the correct location on the image. To change, click on a new location.)

Oxygen at 5 L/minute per nasal cannula is being administered to a 10-year-old child with pneumonia. When planning care for this child, which principle of oxygen administration should the nurse consider?

The client is a 26-year-old female who fell from an apartment balcony. She was transported to the hospital via ambulance. The client enters the emergency room on a stretcher and is met in the trauma bay by the nurse. For the primary survey, what 2 things should the nurse do first?

The nurse is providing discharge instructions to a client with gout in the left great toe who received a prescription for prednisone 30 mg by mouth to be administered each day. Which symptom should the nurse explain is most important for the client to report to the healthcare provider?

The nurse is providing teaching to a client admitted with a blood glucose level of 580 mg/dL about preventing complications related to diabetes mellitus. Which information reported by the client indicates understanding?

The nurse is preparing a client with an acoustic neuroma for a magnetic resonance image (MRI). Which client complaint is life-threatening and should be reported to the healthcare provider immediately?

A client with pancreatic cancer develops ascites, and 2 liters of fluid are removed via paracentesis. Which schedule should the nurse implement to assess the client's blood pressure after this procedure?