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 C
Explanation
Choice A Reason:
NG tube with suction apparatus should not be recommended. NG tubes and suction are not routine equipment for managing cystic fibrosis. They might be used for other medical conditions, such as digestive issues or nutritional support.
Choice B Reason:
Chest tube with a drainage system should not be recommended -. Chest tubes and drainage systems are used to manage conditions like pneumothorax or pleural effusion, which are not directly related to cystic fibrosis.
Choice C Reason:
A chest physiotherapy (CPT) vest, also known as a high-frequency chest wall oscillation (HFCWO) vest, is commonly used by clients with cystic fibrosis to help clear mucus from the lungs. The vest vibrates at high frequency, loosening the mucus and making it easier for the client to cough it up, thus helping to manage respiratory symptoms and reduce the risk of infections.
Choice D Reason:
A peak flow meter is typically used for clients with asthma to measure the maximum speed of exhalation, which helps in assessing asthma control. While it can be useful for monitoring lung function, it is not specific to cystic fibrosis, where the primary concern is airway clearance rather than peak flow measurement.
Correct Answer is A
Explanation
Choice A Reason:
Capillary blood glucose level 164 mg/dl is appropriate. A capillary blood glucose level of 164 mg/dl is above the target range for blood glucose control. In a client receiving total parenteral nutrition (TPN), it's essential to monitor blood glucose levels closely, as hyperglycaemia can lead to complications. The nurse should intervene by notifying the healthcare provider and following the prescribed protocols for managing elevated blood glucose levels in a client with acute pancreatitis receiving TPN.
Choice B Reason:
Crackles in bilateral lower lobes is inappropriate. Crackles in the lungs could be indicative of fluid accumulation or inflammation, which can occur in various conditions. While it should be monitored, it may not require immediate intervention related to the TPN.
Choice C Reason:
WBC count 13,000/mm is inappropriate-. An elevated white blood cell count could be related to the acute pancreatitis itself or other factors. It might require further assessment and monitoring but may not be directly related to the TPN.
Choice D Reason:
Right upper quadrant pain is inappropriate- The client's right upper quadrant pain might be related to the acute pancreatitis or another cause, but it does not specifically indicate a need to intervene with the TPN at this moment.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today