A nurse is caring for a client in the emergency department.
The nurse is caring for the client in the ED. The nurse understands that the client is at risk of developing which of the following complications? Select all that apply.
Hypotension
Respiratory alkalosis
Septic shock
Cardiac arrhythmias
Renal failure
Cerebral edema
Correct Answer : A,D,E,F
A) DKA can lead to several complications, including hypotension, which is indicated by the client's low blood pressure reading of 96/65 mm Hg.
B) Respiratory alkalosis is less likely because DKA typically leads to metabolic acidosis, as indicated by the low pH of 7.30.
C) DKA does not result in septic shock but it instead causes hypovolemic shock in case of severe dehydration.
D) Cardiac arrhythmias can occur due to the electrolyte imbalances, as evidenced by the high potassium level of 5.5 mEq/L.
E) Renal failure is another potential complication, suggested by the elevated creatinine level of 1.7 mg/dL. The client's hyperglycemia and dehydration can stress the kidneys, potentially leading to acute kidney injury or renal failure.
F) Cerebral edema is a less common but severe complication of DKA, especially in children and adolescents, and should be considered given the client's symptoms of frequent urination and extreme thirst. It results from over-hydration of the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) While wearing an N95 respirator may be necessary for certain infections, it is not a routine precaution for clients in protective isolation.
B) Ensuring the client's room has positive-pressure airflow helps prevent the entry of airborne pathogens into the room, reducing the risk of infection for the immunocompromised client.
C) Using disposable plates and utensils helps reduce the risk of cross-contamination and infection transmission but is not directly related to airborne infection control.
D) Monitoring the client's temperature is important for assessing for signs of infection, but it does not directly prevent infection transmission in the same way as positive-pressure airflow.
Correct Answer is ["B","C","D"]
Explanation
A) Infusing 0.9% sodium chloride is incorrect as it's not appropriate for TPN administration.
B) Obtaining the client's weight daily helps to monitor nutritional status and adjust TPN accordingly.
C) Monitoring serum blood glucose is essential due to the high glucose content in TPN, which can lead to hyperglycemia.
D) Verifying the solution with another RN prior to infusion is a safety measure to ensure the correct solution and dosage.
E) Increasing the rate of infusion if administration is delayed may lead to complications and is not appropriate without medical orders.
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