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 D
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
"I will tell your provider that you do not want to take this medication." - This response does not address the client's concerns and might lead to a confrontational approach.
Choice B Reason:
"Your provider wouldn't prescribe this medication if it weren't necessary." Response B is the most appropriate and therapeutic response in this situation. It acknowledges the client's concerns while also emphasizing the importance of following the provider's prescription. By reassuring the client that the provider's decision to prescribe the medication is based on their assessment and medical judgment, the nurse promotes trust and encourages the client to comply with the treatment plan.
Choice C Reason:
"Most clients feel better after taking the antibiotic." - While true, this response doesn't directly address the client's specific concern and might not alleviate their doubts.
Choice D Reason:
"If you don't take this medication, you will feel worse." - This response might come across as overly negative and could potentially lead to resistance or defensiveness from the client. It's important to approach the situation with empathy and respect for the client's perspective.
Correct Answer is B
Explanation
Choice A reason:
Listening to the client's bowel sounds should not be implemented. While assessing bowel sounds is important, it is not the highest priority in this situation. The client's low serum potassium level indicates the potential for serious cardiac arrhythmias, so actions related to monitoring and addressing this electrolyte imbalance are more critical.
Choice B reason:
Initiate cardiac monitoring for the client is the correct answer. A serum potassium level of 2.8 mEq/L is significantly low and can lead to life-threatening cardiac arrhythmias. Initiating cardiac monitoring is crucial to assess the client's heart rhythm and ensure that any potential abnormalities are identified promptly.
Choice C reason:
Check the client's hand grasps should not be implemented. Assessing the client's hand grasps can provide information about muscle strength, but it is not the immediate priority when the client has a critically low potassium level.
Choice D reason:
Administer an IV potassium drip should not be implemented. Administering IV potassium is important for correcting the potassium imbalance, but the priority is to assess and monitor the client's cardiac status first. Rapid administration of potassium can lead to cardiac arrhythmias, so it's important to ensure the heart's stability through cardiac monitoring before administering potassium.
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