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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Using an incentive spirometer is important for improving lung function and preventing atelectasis, but it does not directly address abdominal gas pains.
B. Assisting the client with ambulation is the best action to alleviate abdominal gas pains. Walking helps stimulate peristalsis and can promote the passage of gas, reducing discomfort.
C. Low-fiber food is not recommended for managing abdominal gas pains postoperatively. In fact, high-fiber foods can help prevent constipation and promote bowel movement, which is beneficial for relieving gas.
D. Administering pain medication may be appropriate if the client is in significant pain, but addressing the underlying cause of the pain (gas) by encouraging ambulation is more effective for long-term relief.
Correct Answer is A
Explanation
A. Maintaining the client on NPO (nothing by mouth) status is essential in the management of acute pancreatitis. This helps to rest the pancreas and prevent stimulation of pancreatic enzyme production, which can worsen the condition.
B. Monitoring for hypercalcemia is not a primary focus in acute pancreatitis. Hypocalcemia, rather than hypercalcemia, is more commonly associated with pancreatitis due to the deposition of calcium in areas of fat necrosis.
C. Administering antihypertensive medications is not a priority in the initial management of acute pancreatitis unless the client is also experiencing hypertension. The focus should be on fluid management and preventing complications like infection and shock.
D. Placing the client in a supine position is not recommended for acute pancreatitis. The client should be positioned in a semi-Fowler's position to reduce abdominal pressure and promote comfort.
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