A client is admitted with diabetic ketoacidosis (DKA).
The nurse should anticipate administering which of the following intravenous fluids (Select all that apply).
0.45% sodium chloride solution.
0.9% sodium chloride solution.
5% dextrose in water solution.
Lactated Ringer’s solution.
Regular insulin infusion.
Correct Answer : A,B,E
The nurse should anticipate administering 0.9% sodium chloride solution and regular insulin infusion to a client with diabetic ketoacidosis (DKA).
Choice A is wrong because 0.45% sodium chloride solution is a hypotonic fluid that can cause cerebral edema in DKA patients.
Choice C is wrong because 5% dextrose in water solution can increase blood glucose levels and worsen hyperglycemia in DKA patients.
Choice D is wrong because lactated Ringer’s solution contains lactate, which can be converted to bicarbonate and cause metabolic alkalosis in DKA patients.
Normal ranges for blood glucose, pH, bicarbonate, and ketones are as follows3: Blood glucose: 70-130 mg/dL before meals, and less than 180 mg/dL after meals pH: 7.35-7.45
Bicarbonate: 22-26 mEq/L Ketones: negative or trace
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is a priority nursing intervention for a client with acute kidney injury (AKI) because it helps to assess the renal function and fluid status of the client. Urine output is also an indicator of the response to treatment and the need for further interventions.
Choice A is wrong because pain medication is not a priority intervention for AKI unless the client has other conditions that cause pain.
Pain medication may also have adverse effects on the kidney function and should be used with caution.
Choice C is wrong because ambulation is not a priority intervention for AKI and may not be appropriate for a client who is fluid overloaded or hypotensive.
Ambulation may also increase the risk of falls and injury in a client who is confused or fatigued.
Choice D is wrong because assisting with meals is not a priority intervention for AKI and may not be necessary for a client who has adequate oral intake.
A client with AKI may also have dietary restrictions such as low protein, low potassium, low sodium, and low phosphorus, which should be considered when providing meals.
Correct Answer is A
Explanation
Increased urine output is a sign of adequate hydration, as it means the kidneys are filtering waste and fluids from the body through the urine. The urine should be pale straw or lemonade colored, which indicates good hydration.
Choice B is wrong because decreased urine output is a sign of dehydration, as it means the kidneys are not working well and waste products are accumulating in the blood.
The urine may be dark and strong smelling, which indicates poor hydration.
Choice C is wrong because dry mucous membranes are a sign of dehydration, as they indicate a lack of fluid in the body tissues.
Choice D is wrong because hypertension is not a direct indicator of hydration status, although dehydration can cause low BP due to reduced blood volume.
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