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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Applying medicated powder under the vest is not recommended as it can interfere with the fit of the device, cause skin irritation, or affect the traction. The nurse should avoid using powders or lotions in the area.
B. The nurse should not loosen or tighten the screws on the halo traction device, as this requires a healthcare provider with the appropriate expertise to adjust it. Any adjustments should be made by the physician or specialist.
C. Ensuring that there is space for one finger between the vest and the client's skin is important for preventing skin breakdown and ensuring proper fit of the device. The vest should be snug but not tight enough to cause discomfort or pressure.
D. The nurse should not move the client by holding onto the halo traction device, as this can cause injury or disrupt the device's alignment. Instead, the nurse should use proper techniques and support to move the client safely.
Correct Answer is A
Explanation
A. Isoniazid (INH) can cause liver toxicity, so it is important for the client to have regular liver function tests while taking the medication to monitor for any potential liver damage.
B. Isoniazid is typically prescribed for a longer duration, often 6 to 9 months, for the treatment of tuberculosis. A 1-week course is not sufficient for tuberculosis treatment.
C. Isoniazid does not typically cause an increase in blood pressure. This statement is not accurate regarding the medication’s side effects.
D. Isoniazid should not be taken with antacids because antacids can interfere with the absorption of the medication. Therefore, the client should avoid taking antacids with INH.
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