A nurse in the emergency department is admitting a client who has diabetic ketoacidosis and a blood glucose level of 800 mg/dL. Which of the following interventions should the nurse initiate first?

Potassium chloride 10 mEq/hr

Bicarbonate by IV infusion

Subcutaneous insulin injections

0.9% sodium chloride 15 mL/kg/hr

Answer and Explanation

The Correct Answer is D

Choice A rationale: While potassium replacement is important in diabetic ketoacidosis, fluid resuscitation to restore intravascular volume, improve renal perfusion, and flush out ketones.
Choice B rationale: Bicarbonate infusion might be considered in severe acidosis, but fluid administration is the priority.
Choice C rationale: The priority intervention for a client with diabetic ketoacidosis and very high blood glucose levels is to initiate fluid resuscitation to restore intravascular volume, improve renal perfusion, and flush out ketones.
Choice D rationale: The first intervention the nurse should initiate is fluid resuscitation with 0.9% sodium chloride at a rate of 15 mL/kg/hr to restore intravascular volume, improve renal perfusion, and flush out ketones.

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Correct Answer is C

Explanation

Choice A rationale: Presence of pedal pulses bilaterally is a normal finding and does not reflect the status of the blood clot.
Choice B rationale: Decreased INR is a measure of how quickly the blood clots and is used to monitor warfarin therapy, not heparin therapy.
Choice C rationale: A reduced calf circumference indicates that the swelling caused by the blood clot has decreased, which means that the heparin therapy is working.
Choice D rationale: Platelet levels are not the primary indicator of the effectiveness of heparin therapy for deep-vein thrombosis.

A. Increased blood pressure B. Hypertonia C. Wheezing D. Urinary retention

Correct Answer is C

Explanation

Choice A rationale: While increased blood pressure can occur in various conditions, it might not specifically indicate anaphylaxis to penicillin.

Choice B rationale: Hypertonia might not directly correlate with anaphylaxis and could be caused by other factors.

Choice C rationale: Wheezing is a critical sign of anaphylaxis, a severe allergic reaction to penicillin. Reporting wheezing to the provider is crucial for immediate intervention to prevent further complications associated with anaphylaxis.

Choice D rationale: Urinary retention is not a typical manifestation of anaphylaxis to penicillin and might not be directly linked to the allergic reaction.

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A nurse in the emergency department is admitting a client who has diabetic ketoacidosis and a blood glucose level of 800 mg/dL. Which of the following interventions should the nurse initiate first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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