A client with diabetic ketoacidosis (DKA) 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). What additional laboratory result is most important for the nurse to monitor?
Serum sodium.
Serum potassium.
Blood urea nitrogen (BUN).
Urine ketones.
The Correct Answer is B
Choice A rationale
While monitoring serum sodium levels is important in a client with DKA, it is not the most critical. Hyperglycemia can lead to a state of effective osmotic diuresis, which can cause sodium depletion.
Choice B rationale
Serum potassium levels are crucial to monitor in a client with DKA3. Despite total body potassium depletion, serum potassium levels may be high or normal upon presentation due to acidosis and insulin deficiency. However, with insulin treatment, potassium will shift back into the cells, potentially leading to life-threatening hypokalemia.
Choice C rationale
Blood urea nitrogen (BUN) might be elevated due to dehydration, but it is not the most critical lab value to monitor in the management of DKA3.
Choice D rationale
Urine ketones are not as important to monitor as serum potassium in DKA. The presence of ketones in urine only confirms that the body is breaking down fat, not the severity of DKA3.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Administering the medication at 1000, 1600, 2200, and 0400 would not be the best schedule because it does not evenly distribute the doses throughout the day. This could lead to periods of subtherapeutic medication levels and periods of potential toxicity.
Choice B rationale
Administering the medication with meals and a bedtime snack is not the best schedule for this medication. While some medications need to be administered with food, there is no indication
that this medication needs to be. Furthermore, this schedule could lead to uneven distribution of the medication throughout the day.
Choice C rationale
Giving the medication in equally divided doses during waking hours is not the best schedule because it does not take into account the half-life of the medication or the patient’s sleep schedule. This could lead to subtherapeutic levels of the medication during the night.
Choice D rationale
Administering the medication at 0800, 1200, 1600, and 2000 is the best schedule for this medication. It evenly distributes the doses throughout the day, which can help maintain a therapeutic level of the medication and reduce the risk of toxicity.
Correct Answer is D
Explanation
Choice A rationale
Determining the presence of ST-elevations or non-ST-elevations on the electrocardiogram is an important step in diagnosing a myocardial infarction. However, this is typically performed by a healthcare provider or a trained technician, not a nurse.
Choice B rationale
While creating a calm and quiet environment can be beneficial for a client experiencing chest pain, it is not the immediate intervention that should be performed. The client’s symptoms suggest a possible cardiac event, which requires immediate medical intervention.
Choice C rationale
Verifying that troponin level assessments are scheduled every 3-6 hours for a series of three is important for diagnosing myocardial infarction. However, this is not the immediate intervention that should be performed. The client’s symptoms suggest a possible cardiac event, which requires immediate medical intervention.
Choice D rationale
Applying oxygen via nasal cannula and titrating to keep oxygen saturation above 93% is the correct intervention. This action helps to increase the oxygen supply to the myocardium, potentially decreasing the extent of myocardial damage and relieving chest pain.
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