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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason:

Bradycardia is incorrect. Bradycardia refers to a slow heart rate, and while anaemia can lead to an increased heart rate (tachycardia) as the body tries to compensate for the decreased oxygen levels, it is not typically associated with bradycardia.

Choice B reason:

Headache Anaemia is a condition characterized by a decreased number of red blood cells or a decrease in the amount of haemoglobin in the blood, leading to reduced oxygen-carrying capacity. This can result in decreased oxygen delivery to various tissues and organs, including the brain. As a result, clients with anaemia often experience symptoms such as fatigue, weakness, and headaches.

Choice C reason:

Flushed skin colour - Anaemia is more likely to cause paleness of the skin (pallor) due to the decreased haemoglobin levels, rather than flushed skin colour.

Choice D reason:

Heat intolerance - Heat intolerance is not a typical symptom of anaemia. It might be seen in conditions affecting the thyroid or related to hormonal imbalances, but it is not directly related to anaemia.

A. Bradycardia B. Hypertension C. Back pain D. Chills

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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A nurse is caring for a client in diabetic ketoacidosis (DKA). Which of the following is the priority intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has anemia. Which of the following assessment findings should the nurse anticipate with the client's condition?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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