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:
A calcium level of 11.5 mg/dL is elevated. Normal calcium levels typically range from 8.5 to 10.5 mg/dL. Hypercalcemia can lead to various complications, including cardiac arrhythmias and neurological symptoms. The nurse should notify the provider of this finding for further evaluation and management.Choice B reason
Serum albumin level 3.9 g/dL is not appropriate. This level is within a reasonable range for serum albumin. It might be an indicator of nutritional status, but it's not an urgent concern.
Choice C reason:
Output exceeding intake over a 12-hour period may indicate fluid imbalance or inadequate intake compared to output. However, without further context, such as the client's overall fluid status, this finding alone may not be alarming. The nurse should assess the client's hydration status, consider potential causes of increased output, and address any concerns accordingly. While the nurse may need to monitor closely and address any potential issues, immediate notification of the provider may not be necessary based solely on this finding.Choice D reason:
Fasting blood glucose level 105 mg/dL is not appropriate: A fasting blood glucose level of 105 mg/dL is slightly elevated, but it's not a critically high value. The nurse should monitor blood glucose levels and collaborate with the healthcare team to manage blood glucose appropriately.
However, if the client has a history of diabetes or if there are other concerning factors, such as consistent high glucose levels or symptoms of hyperglycemia, the nurse may need to monitor closely and notify the provider for further evaluation and management. Otherwise, this finding alone may not warrant immediate notification.Correct Answer is C
Explanation
Choice A Reason:
COPD (Chronic Obstructive Pulmonary Disease) - While COPD might influence the choice of anaesthesia and perioperative management, it is not a direct contraindication to heparin.
Choice B Reason:
Thalassemia - Thalassemia is a genetic blood disorder that affects haemoglobin production and the structure of red blood cells. It does not directly impact the ability to receive heparin.
Choice C Reason:
Thrombocytopenia. Thrombocytopenia, which is a low platelet count, is a contraindication to receiving heparin, an anticoagulant. Heparin works by preventing the formation of blood clots, but if a person has a low platelet count, their ability to form blood clots is already compromised. Administering heparin in this situation could increase the risk of bleeding and further reduce platelet count.
Choice D Reason:
Rheumatoid arthritis - Rheumatoid arthritis is an autoimmune condition affecting joints. It is not a contraindication to heparin use, but the client's overall health and medications should be considered when planning surgery and anticoagulant therapy.
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