A nurse is caring for a client in diabetic ketoacidosis (DKA).
Which of the following is the priority intervention by the nurse?
Check potassium levels.
Begin bicarbonate continuous IV infusion.
Initiate a continuous IV insulin infusion.
Administer 0.9% sodium chloride.
The Correct Answer is D
The correct answer is Choice D.
Choice A rationale: Checking potassium levels is important in the management of DKA, but it is not the priority intervention. The priority intervention is to restore intravascular volume with fluid resuscitation
Choice B rationale: Bicarbonate infusion is not the priority intervention in the management of DKA. It is used only in severe cases of metabolic acidosis
Choice C rationale: Initiation of a continuous IV insulin infusion is an important intervention in the management of DKA, but it is not the priority intervention. The priority intervention is to restore intravascular volume with fluid resuscitation
Choice D rationale: Administering 0.9% sodium chloride is the priority intervention in the management of DKA. It is used to restore intravascular volume and correct electrolyte imbalances
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The priority intervention for a nurse planning care for a client who has status epilepticus is to administer diazepam intravenously to the client.
Diazepam is a benzodiazepine medication that can help stop seizure activity and is often used as a first-line treatment for status epilepticus.
Choice A is incorrect because while phenytoin can be used to treat seizures, it is not typically used as a first-line treatment for status epilepticus.
Choice C is incorrect because while providing oxygen can be an important intervention for clients experiencing seizures, it is not the priority intervention.
Choice D is incorrect because while turning the client to the lateral position during seizure activity can help prevent aspiration, it is not the priority intervention.
Correct Answer is A
Explanation
The correct answer is A. Back pain.
Choice A reason: Back pain during a blood transfusion is a classic symptom of a hemolytic transfusion reaction. This type of reaction occurs when the immune system attacks the transfused red blood cells, leading to their destruction. Back pain is considered a more specific and early sign of this reaction.
Choice B reason: Bradycardia, which is a slower than normal heart rate, is not typically associated with hemolytic transfusion reactions. The normal range for an adult’s resting heart rate is between 60 to 100 beats per minute. Bradycardia is usually considered when the heart rate is lower than 60 beats per minute in a resting adult. It can be a sign of a well-trained athlete or can occur as a result of certain medications or heart conditions, but it is not a recognized symptom of a hemolytic transfusion reaction.
Choice C reason: Hypertension, or high blood pressure, is also not a common symptom of a hemolytic transfusion reaction. Normal blood pressure ranges from 90/60 mmHg to 120/80 mmHg. Hypertension is typically defined as having a blood pressure higher than 130/80 mmHg. While hypertension can be a serious condition, it is not indicative of a hemolytic transfusion reaction.
Choice D reason: Chills are a symptom that can be associated with a hemolytic transfusion reaction, often occurring alongside fever and back pain. However, while chills can indicate a reaction, back pain is a more specific symptom that can help differentiate a hemolytic reaction from other types of transfusion reactions.
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