A client with diabetic ketoacidosis (DK
Measure the client's blood pressure manually.
Administer intravenous fluids.
Place the client on oxygen therapy.
Administer subcutaneous insulin.
The Correct Answer is B
Choice A rationale
Measuring blood pressure manually is important in assessing the patient's hemodynamic status, but it is not the priority intervention in diabetic ketoacidosis (DKA). The priority is to address dehydration and electrolyte imbalances.
Choice B rationale
Administering intravenous fluids is the priority intervention for a client with DKA. Rapid, deep respirations (Kussmaul breathing) indicate severe metabolic acidosis and dehydration. IV fluids help to correct fluid deficit, improve perfusion, and decrease blood glucose levels.
Choice C rationale
Oxygen therapy may be beneficial if the client is hypoxic, but it is not the priority intervention for DKA. The primary issue is fluid deficit and metabolic acidosis.
Choice D rationale
Administering subcutaneous insulin is essential for managing hyperglycemia in DKA, but it should be done after initiating IV fluids to avoid rapid shifts in electrolyte balance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A terminal ileostomy involves creating an opening in the right lower quadrant of the abdomen where the ileum is brought to the surface to form a stoma for waste elimination.
Choice B rationale
The left lower quadrant is not used for a terminal ileostomy, as it is not anatomically appropriate for the ileum.
Choice C rationale
The right upper quadrant is not relevant to a terminal ileostomy because the ileum is located in the lower part of the abdomen.
Choice D rationale
The left upper quadrant is also inappropriate for a terminal ileostomy due to the anatomical position of the ileum.
Correct Answer is A
Explanation
Choice A rationale
Inability to locate the dorsalis pedis pulse and increasing pain are signs of compromised circulation, requiring immediate intervention.
Choice B rationale
Pain relieved by medication does not indicate an urgent situation and suggests effective pain management.
Choice C rationale
Generalized weakness and increased sensitivity to touch are not typically indicative of a critical emergency requiring immediate reporting.
Choice D rationale
Localized edema and discoloration are expected findings following a fracture and do not necessitate immediate reporting.
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