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

Check potassium levels.

Administer 0.9% sodium chloride.

Begin bicarbonate continuous IV infusion.

Initiate a continuous IV insulin infusion.

Answer and Explanation

The Correct Answer is B

A. Checking potassium levels is important in the management of DKA, but it is not the priority intervention. Potassium levels should be monitored closely, as insulin therapy can lower potassium levels, but the first step in treatment is fluid resuscitation.

B. Administering 0.9% sodium chloride (normal saline) is the priority intervention in DKA. This helps to correct dehydration and restore circulatory volume, which is critical in stabilizing the client. Fluid replacement is the first step in managing DKA before insulin is administered.

C. Beginning bicarbonate continuous IV infusion is typically not recommended unless the pH is extremely low (below 6.9). The primary treatment in DKA is fluid and insulin therapy, and bicarbonate is used only in severe cases of acidosis.

D. Initiating a continuous IV insulin infusion is essential in treating DKA, but it should be done after initial fluid resuscitation. Insulin therapy lowers blood glucose and helps to resolve ketosis, but fluid replacement is the first priority to stabilize the client.

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Correct Answer is ["C","D","E","G"]

Explanation

A. Blood glucose level: The blood glucose level is within the normal range (103 mg/dL), so there is no immediate concern for hypoglycemia or hyperglycemia at this moment. While the client has diabetes, this finding does not require immediate follow-up.

B. Bowel sounds: Bowel sounds are present in all 4 quadrants, indicating normal gastrointestinal function. There is no indication of gastrointestinal distress, so this does not require immediate follow-up.

C. Blood pressure: The blood pressure is not provided in the scenario, but if it were hypotensive or elevated, it would be important to follow up. Hypotension could indicate a lack of perfusion, and hypertension could indicate worsening cardiac stress. Blood pressure should be monitored closely in this client, especially with suspected cardiac issues.

D. Pain level: The client reports chest pain radiating to the left arm, which is a classic symptom of myocardial infarction (MI). Immediate follow-up is needed to address pain management and investigate the cause of the pain. This could be a sign of acute coronary syndrome, requiring urgent intervention.

E. Electrocardiogram findings: The electrocardiogram (ECG) shows tachycardia with ST segment elevation and T wave changes, which are indicative of a myocardial infarction (MI). These findings require immediate follow-up and urgent medical intervention to assess and treat the possible heart attack.

F. Lung sounds: The lung sounds are clear in all lobes, indicating no respiratory distress or issues with lung function. This does not require immediate follow-up.

G. Troponin T level: The troponin T level is elevated at 0.40 ng/mL (normal is less than 0.1 ng/mL), which is a key marker for myocardial injury. This finding requires immediate follow-up to assess the severity of the cardiac event and initiate treatment for potential myocardial infarction.

A. Temperature B. Gag reflex C. Warmth of extremities D. Level of pain

Correct Answer is B

Explanation

A. While monitoring the client's temperature is important, it is not the highest priority immediately following sedation.

B. The gag reflex is a critical assessment after moderate sedation, especially following procedures like endoscopy, as it ensures that the client can protect their airway and swallow safely. If the gag reflex is not intact, there is a risk of aspiration or airway obstruction.

C. Warmth of extremities is an important sign of circulation, but it is not as critical as the gag reflex after a procedure involving sedation and airway manipulation.

D. Level of pain is important, but it is secondary to ensuring that the client’s airway is protected. Pain management can be addressed once the client's airway and safety are ensured.

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

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