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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["400"]

Explanation

Step 1: Convert the volume of fluid to be infused from mL to L (since the rate is usually measured in mL/hr):

200 mL = 200 mL (No conversion needed as the volume is already in mL)

Step 2: Convert the time for infusion from minutes to hours (since the rate is usually measured in mL/hr):

30 minutes = 30 ÷ 60 = 0.5 hours

Step 3: Calculate the rate (volume ÷ time):

Rate = Volume ÷ Time

Rate = 200 mL ÷ 0.5 hours

Rate = 400 mL/hr

The nurse should program the infusion pump to deliver at a rate of 400 mL/hr.

A. "What did the night nurse do that makes you think the nurse is aloof?" B. "Tomorrow I will talk to that nurse about how you were treated last night." C. "I am happy that you are getting better and will be able to go home." D. "I am glad you like me. Which nurse was acting aloof to you?"

Correct Answer is C

Explanation

Choice A reason: Asking for specifics about the night nurse's behavior could reinforce the client's splitting behavior, which is not therapeutic.

Choice B reason: Promising to talk to the night nurse may validate the client's negative perception without understanding the full context.

Choice C reason: Focusing on the client's progress and upcoming discharge avoids engaging in a discussion that could reinforce dichotomous thinking.This response is non-confrontational and avoids engaging in the client’s dichotomous thinking. It focuses on the positive aspect of the client’s situation, which is their improvement and discharge from the hospital. It’s important for healthcare professionals to maintain professional boundaries and not reinforce potentially harmful behavior patterns.

Choice D reason: Seeking details about the client's preference for certain staff can encourage splitting behavior and is not beneficial.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["400"]

Explanation

Correct Answer is C

Explanation

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