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 D
Explanation
Choice A Reason:
Blurred vision is incorrectly. Blurred vision is not a common complication of immobility and is more likely related to other factors.
Choice B Reason:
Polyuria is incorrect. Increased urination (polyuria) is not directly related to immobility; it can be caused by various factors, such as fluid intake, medications, or underlying medical conditions.
Choice C Reason:
Diarrhea is incorrect. While immobility can contribute to constipation due to reduced activity and decreased bowel motility, it is not typically associated with diarrhea
Choice D Reason:
Confusion is correct. Confusion can be a potential complication of immobility in bedridden clients. Prolonged immobility can lead to reduced sensory stimulation, altered sleep patterns, and decreased cognitive engagement, which can contribute to confusion and cognitive decline.
Correct Answer is C
Explanation
Choice A Reason:
Peripheral pulses 2+ bilaterally - This indicates good peripheral circulation and is not typically a concerning finding.
Choice B Reason:
Creatinine 0.8 mg/dL - A creatinine level of 0.8 mg/dL is within the normal range and does not indicate acute kidney failure.
Choice C Reason:
Urine specific gravity 1.045 A urine specific gravity of 1.045 is significantly elevated and could indicate concentrated urine, which might be a concern in a client with acute kidney failure. Elevated specific gravity could suggest dehydration, impaired kidney function, or other kidney-related issues. The nurse should report this finding to the provider for further evaluation and intervention.
Choice D Reason:
Weight gain 1.1 kg (2.4 lb) in 24 hr - While weight gain should be monitored closely in clients with kidney failure, 1.1 kg in 24 hours might not be an immediate concern, depending on the client's overall condition and baseline weight. However, it should still be followed up on in subsequent assessments.
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