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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale

Increasing fluid intake is contraindicated in clients with fluid overload, such as those with bilateral lower extremity edema and lung crackles. It can worsen the condition.

Choice B rationale

Administering prescribed diuretics is the priority intervention to reduce fluid overload in clients with heart failure post-STEMI. It helps to decrease edema and pulmonary congestion.

Choice C rationale

Applying warm compresses to the lower extremities may provide temporary relief but does not address the underlying issue of fluid overload.

Choice D rationale

Encouraging ambulation is beneficial for overall health but is not a priority intervention for managing fluid overload in this context. .

A. Right lower quadrant. B. Left lower quadrant. C. Right upper quadrant. D. Left upper quadrant.

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.

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A client with diabetic ketoacidosis (DK

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a recent ST segment elevation MI (STEMI) presents with bilateral lower extremity edema and crackles throughout the lung fields.What is the nurse's priority intervention for this client?

Correct Answer is B

Explanation

A client diagnosed with ulcerative colitis is scheduled for a terminal ileostomy.The nurse is aware the stoma will be in what area of the client's abdomen?

Correct Answer is A

Explanation

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