A client with type 1 diabetes mellitus (DM) is admitted in diabetic ketoacidosis. Treatment is initiated, and the nurse is preparing to administer IV fluids containing potassium chloride. Which assessment data is most important for the nurse to obtain before starting the infusion?
Urinary output of 30 to 60 mL/hr.
Magnesium level.
Size of the IV catheter.
Serum glucose level.
The Correct Answer is A
Choice A reason: Before administering IV fluids containing potassium chloride, it is crucial to ensure that the client has adequate urinary output, typically between 30 to 60 mL/hr. This indicates good kidney function, which is necessary for the excretion of potassium to prevent hyperkalemia, a potentially life-threatening condition.
Choice B reason: While magnesium levels can affect potassium levels, they are not the most critical assessment before potassium infusion. However, it is important to monitor magnesium levels as part of the overall electrolyte balance, especially in diabetic ketoacidosis.
Choice C reason: The size of the IV catheter is important for administration purposes, but it is not the most critical assessment data before starting potassium infusion. The catheter size affects the flow rate and comfort during infusion but does not impact the decision to start the infusion.
Choice D reason: Serum glucose level is a vital parameter to monitor in diabetic ketoacidosis, but it is not the most critical assessment before starting potassium infusion. The primary concern with potassium infusion is kidney function, as assessed by urinary output.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Hypothermia is not typically associated with hyperparathyroidism and does not require specific precautions in this context.
Choice B reason: Aspiration may be a concern for patients with severe hypercalcemia if they have altered mental status, but it is not the primary safety precaution.
Choice C reason: Falls are a significant risk due to potential muscle weakness, skeletal fragility, and possible neuromuscular symptoms caused by hypercalcemia.
Choice D reason: Suicide is not directly related to hyperparathyroidism; however, mental health should always be monitored in patients with chronic conditions.
Correct Answer is B
Explanation
Choice A reason:Deferring to the provider does not address the confidentiality issue; it suggests the nurse is unwilling rather than clarifying the legal obligation to protect an adult client’s health information.
Choice B reason: By stating that only the client can authorize release of their own medical data, the nurse accurately reflects HIPAA and patient‑privacy regulations for an adult. This response both informs the parent and upholds the client’s right to confidentiality.
Choice C reason: This response is inappropriate and unprofessional. It fails to acknowledge the parent's concern and does not provide a constructive way to address the situation.
Choice D reason: While this response may seem helpful, it is not the nurse's role to promise lab results, especially when there are privacy laws that restrict the sharing of medical information with anyone other than the patient unless consent has been given.
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