A client with type 1 diabetes mellitus (DM) is admitted to the hospital for an emergency cholecystectomy. The client explains to the nurse about experiencing difficulty at home in keeping blood glucose levels under 200 mg/dl (11.1 mmol/L). To prevent the client from developing diabetic ketoacidosis (DKA), which intervention is most important for the nurse to include in the plan of care?
a) Obtain a fingerstick glucose every 6 hours.
b) Ensure IV fluids are infusing continuously.
c) Test urine for the presence of ketones.
d) Teach the client how to manage sick days.

The correct answer is: c) Test urine for the presence of ketones.

Choice A reason: Obtaining a fingerstick glucose every 6 hours is important for monitoring blood glucose levels and ensuring they are within the target range. However, it is not the most critical intervention for preventing diabetic ketoacidosis. Testing for ketones provides more specific information on the development of DK

Obtain a fingerstick glucose every 6 hours.

Ensure IV fluids are infusing continuously.

Test urine for the presence of ketones.

Teach the client how to manage sick days.

Answer and Explanation

The Correct Answer is C

Choice A reason: Obtaining a fingerstick glucose every 6 hours is important for monitoring blood glucose levels and ensuring they are within the target range. However, it is not the most critical intervention for preventing diabetic ketoacidosis. Testing for ketones provides more specific information on the development of DKA.

Choice B reason: Ensuring IV fluids are infusing continuously is crucial for maintaining hydration and preventing electrolyte imbalances, particularly in a client who may be at risk for DKA. However, this intervention is supportive and not as directly related to detecting the onset of DKA as testing for ketones.

Choice C reason: Testing urine for the presence of ketones is the most important intervention. The presence of ketones indicates that the body is breaking down fat for energy instead of using glucose, which is a hallmark of diabetic ketoacidosis. Early detection of ketones allows for prompt intervention to prevent the progression of DKA.

Choice D reason: Teaching the client how to manage sick days is essential for long-term diabetes management and preventing complications during illness. However, for the immediate prevention of DKA in the hospital setting, testing for ketones is more urgent and directly related to detecting and managing the condition.

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Correct Answer is B

Explanation

Choice A reason: Denial of urinary frequency, urgency, or dysuria is a good sign of symptom relief but does not directly confirm the success of the lithotripsy in terms of stone removal.

Choice B reason: The presence of stone fragments in the urine after lithotripsy indicates that the procedure successfully broke up the kidney stones, allowing them to be excreted. This is a direct and specific measure of the procedure's effectiveness.

Choice C reason: Pale pink urine with no observable blood clots is a positive sign and suggests that there is no significant bleeding, but it does not directly confirm the removal of the kidney stones.

Choice D reason: Normal serum creatinine and blood urea nitrogen (BUN) levels indicate good kidney function but do not specifically reflect the success of the lithotripsy in breaking up and removing the stones.

A. Place the client in a darkened room. B. Obtain blood pressure reading. C. Administer an oral analgesic. D. Perform finger stick glucose.

Correct Answer is B

Explanation

Choice A reason: Placing the client in a darkened room may help alleviate symptoms if the headache is related to migraine or sensitivity to light, but it does not address the potential underlying cause of the severe headache and blurred vision in a client with a history of diabetes and hypertension.

Choice B reason: Obtaining a blood pressure reading is the most critical first step. Severe headache and blurred vision can be symptoms of hypertensive crisis, which is a medical emergency that requires immediate attention to prevent complications such as stroke or organ damage. Checking the blood pressure will help determine if the client's symptoms are due to elevated blood pressure.

Choice C reason: Administering an oral analgesic may provide temporary relief for the headache, but it does not address the potential underlying causes of the symptoms. The priority is to assess and manage any potentially life-threatening conditions.

Choice D reason: Performing a finger stick glucose test is important for monitoring blood glucose levels in a client with diabetes. However, in the context of the severe headache and blurred vision, the immediate concern should be to rule out hypertensive crisis by checking the blood pressure first. Blood glucose can be checked after ensuring the client's blood pressure is not critically high.

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Naxlex Comprehensive Predictor Exams

While assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the procedure was successful?

Correct Answer is B

Explanation

A client with a history of diabetes mellitus and hypertension received new medication prescriptions three days ago. Today the client returns to the clinic reporting a severe headache and blurred vision. Which intervention should the nurse implement first?

Correct Answer is B

Explanation

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