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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Correct Answer is D

Explanation

A. "How do you cope with the voices?" is an important question to assess the client's coping mechanisms, but it does not provide direct information about the content or nature of the auditory hallucinations. While coping strategies are relevant, understanding the nature of the hallucinations is crucial for treatment planning.

B. "When do you hear voices?" is important to understand the timing and frequency of the hallucinations, but it does not provide information about the content or nature of the hallucinations themselves.

C. "Which medication works best?" is important to assess the client's previous treatment history and response to medication, but it does not directly address the current assessment of the auditory hallucinations.

D. "What are the voices saying?" is the most important question because it directly addresses the content and nature of the auditory hallucinations. Understanding the specific content, tone, and perceived significance of the voices can provide valuable information for diagnosis, treatment planning, and assessing the client's level of distress or impairment.

A. Apply a water-soluble lubricant to the catheter. B. Wear protective goggles while performing the procedure. C. Instill 3 mL of normal saline before suctioning. D. Instruct the client to cough as the suction tip is removed.

Correct Answer is B

Explanation

A. Apply a water-soluble lubricant to the catheter. Lubricating the suction catheter can facilitate insertion, but applying a lubricant is not the primary action needed to address excessive drooling.
Additionally, water-soluble lubricants may not provide adequate protection against potential splashes or droplets.
B. Wear protective goggles while performing the procedure. Excessive drooling in a client with ALS may increase the risk of exposure to saliva and potential aerosolized droplets during
suctioning. Wearing protective goggles helps prevent exposure to bodily fluids and reduces the risk of infection for the nurse.
C. Instill 3 mL of normal saline before suctioning. Instilling normal saline before suctioning is not typically indicated for oral suctioning in a client with excessive drooling. This action may increase the risk of aspiration and is unnecessary for managing drooling.
D. Instruct the client to cough as the suction tip is removed. Instructing the client to cough is not appropriate for oral suctioning. Coughing may increase the production of saliva and exacerbate drooling. Additionally, this action does not address the nurse's safety during the suctioning
procedure.

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Naxlex Comprehensive Predictor Exams

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. Which question is most important for the nurse to include in the assessment of this client?

Correct Answer is D

Explanation

The nurse observes a client with amyotrophic lateral sclerosis (ALS) is excessively drooling and prepares to suction the client's oral cavity. Which action should the nurse include?

Correct Answer is B

Explanation

An intravenous (IV) antibiotic is prescribed for a client with a postoperative infection. The medication is to be administered in 4 divided doses. Which schedule is best for administering this prescription?

The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled "750 mcg/2.4 mL". How many ml. should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

The nurse is teaching a primigravida about preeclampsia. What finding(s) are indicators of preeclampsia and should be reported to the healthcare provider? Select all that apply.

A client with chronic obstructive pulmonary disease (COPD) receives a prescription for chest physiotherapy (CPT) to help mobilize secretions. Following the therapy, which finding indicates to the nurse that the intervention was effective?

The nurse is teaching a group of women about osteoporosis and exercise. The nurse should emphasize the need for which type of regular activity?

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?