A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse?
initiate a continuous IV insulin infusion
Begin bicarbonate continuous IV infusion
Check potassium levels
Administer 0.9% sodium chloride
The Correct Answer is A
Choice A reason:
Initiating a continuous IV insulin infusion is the first priority. The priority intervention for a client in diabetic ketoacidosis (DKA) is to normalize blood glucose levels and reverse the ketoacidosis. Initiating a continuous IV insulin infusion is essential to rapidly lower the elevated blood glucose levels and counteract the metabolic acidosis associated with DKA.
Choice B reason:
Beginning a bicarbonate continuous IV infusion is generally not the priority in DKA management. While metabolic acidosis is a concern in DKA, insulin therapy and fluid resuscitation are typically the initial focus of treatment.
Choice C reason:
Checking potassium levels is important since potassium imbalances are common in DKA. However, while this is important, it is not the first priority. It's important to ensure that insulin therapy has been initiated before addressing potassium levels.
Choice D reason:
Administering 0.9% sodium chloride (normal saline) is a crucial part of DKA treatment but it is not the first priority as it helps correct dehydration and electrolyte imbalances. However, starting insulin therapy to address the underlying metabolic issue takes precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Confirming the correct position of the line by obtaining a blood sample is appropriate. Inserting a central venous catheter is a procedure that involves placing a catheter into a large vein, typically in the neck, chest, or groin. Confirming the correct placement is crucial to prevent complications such as pneumothorax (lung collapse) or catheter misplacement.
Choice B reason:
Instructing the client to cough as the catheter is inserted is not a standard practice during central venous catheter insertion and could lead to unnecessary complications.
Choice C reason:
Placing the head of the client's bed lower than the foot (Trendelenburg position) is not a standard practice during central venous catheter insertion and would not be helpful for this procedure.
Choice D reason:
Cleansing the site with hydrogen peroxide is not the recommended method for central venous catheter insertion. Typically, a sterile technique and appropriate antiseptic solution are used to reduce the risk of infection.
Correct Answer is C
Explanation
Choice A Reason:
Bradycardia - Bradycardia is not a typical symptom of a haemolytic transfusion reaction.
Choice B Reason;
Hypertension - Hypertension is not a common manifestation of a haemolytic transfusion reaction.
Choice C Reason:
Back pain A haemolytic transfusion reaction is a severe and potentially life-threatening complication that can occur when the immune system reacts against the transfused red blood cells. Back pain is a classic symptom of a haemolytic transfusion reaction. It is often accompanied by other symptoms such as fever, chills, chest pain, dyspnoea, nausea, vomiting, haematuria, and hemoglobinuria (presence of haemoglobin in the urine).
Choice D Reason:
Chills - Chills can occur in various types of transfusion reactions, including haemolytic reactions, but they are not as specific as back pain for indicating a haemolytic transfusion reaction.
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