A nurse is caring for an adolescent who has diabetic ketoacidosis (DKA). The nurse notes the following findings:
- capillary refill is greater than 4 seconds
- peripheral pulses are rapid and weak,
- guardian reports it has been over 12 hours since adolescent last voided and for the past 6 hours has not been able to retain any oral fluids,
- respirations are deep and rapid, breath has an acetone odor to it.
- Adolescent does ask for a drink and cries out that they are thirsty.
- Bedside glucose monitor shows glucose is above 500 mg/dL.
- Provider notified immediately.
09:00:
2 peripheral IVs were started in the antecubital space. Bloodwork drawn via left antecubital IV and sent STAT to laboratory. IV of 0.9% sodium chloride infusing in the right antecubital IV at 200 mL/hr. No edema or drainage at IV site. Placed on cardiac monitor and is transported to the PICU.
PICU
09:15:
14-year-old received from the emergency department for treatment of DKA. Guardian is present. Adolescent placed on cardiac monitor. IV fluid of 0.9% NaCl is infusing at 200 mL/hr in antecubital IV. No edema or drainage at IV site. Child is yelling for a drink of water. Explained that they are not able to have anything by mouth at this time. Kussmaul respirations and fruity smelling breath noted. Sinus tachycardia is noted on monitor. Laboratory called with results from the bloodwork. Provider is notified.
The nurse should anticipate the provider's prescriptions for this client to include which of the following? (Select all that apply.)
Subcutaneous insulin every 2 hours until glucose is below 300 mg/dL
IV regular insulin
IV potassium chloride
Oxygen via nasal cannula
The Correct Answer is B
Choice A reason: Subcutaneous insulin is not the preferred route for a client with DKA, as it has a slower onset and peak than IV insulin. IV regular insulin is the preferred route, as it provides a rapid and continuous infusion of insulin that can be titrated according to the blood glucose level.
Choice B reason: IV regular insulin is the medication of choice for a client with DKA, as it lowers the blood glucose level and reverses the ketosis and acidosis. IV regular insulin has a rapid onset and peak, and can be adjusted based on the client's response.
Choice C reason: IV potassium chloride is indicated for a client with DKA, as the client is at risk of hypokalemia due to osmotic diuresis, insulin therapy, and metabolic acidosis. IV potassium chloride can prevent or treat hypokalemia and its complications, such as cardiac arrhythmias.
Choice D reason: Oxygen via nasal cannula is not necessary for a client with DKA, unless the client has signs of hypoxia or respiratory distress. The client's deep and rapid respirations are a compensatory mechanism for the metabolic acidosis, and do not indicate a need for oxygen therapy.
Choice E reason: Sodium bicarbonate is not recommended for a client with DKA, as it can cause paradoxical cerebral acidosis, hypokalemia, and impaired oxygen delivery. The client's acidosis can be corrected by IV insulin and fluid therapy, which will restore the normal metabolism of glucose and ketones.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Bacterial meningitis is a probable condition, as it is an infection of the membranes that cover the brain and spinal cord, caused by various bacteria, such as Streptococcus pneumoniae, Neisseria meningitidis, or Haemophilus influenzae. The adolescent has many signs and symptoms of bacterial meningitis, such as fever, headache, and neck stiffness.
Choice B reason: Viral meningitis is not a likely condition, as it is an infection of the membranes that cover the brain and spinal cord, caused by various viruses, such as enteroviruses, herpes simplex virus, or mumps virus. The adolescent has some signs and symptoms of viral meningitis, such as fever, headache, and neck stiffness, but they are usually less severe than bacterial meningitis.
Choice C reason: Encephalitis is not a probable condition, as it is an inflammation of the brain tissue, usually caused by viral infections, such as herpes simplex virus, West Nile virus, or rabies virus. The adolescent has some signs and symptoms of encephalitis, such as fever, headache, and altered mental status, but they are usually accompanied by focal neurological deficits, such as seizures, paralysis, or cranial nerve palsies.
Choice D reason: Brain abscess is not a definite condition, as it is a collection of pus within the brain tissue, usually caused by bacterial infections that spread from other parts of the body, such as the ear, sinus, or lung. The adolescent has some signs and symptoms of brain abscess, such as fever, headache, and altered mental status, but they are usually accompanied by focal neurological deficits, such as seizures, paralysis, or cranial nerve palsies.
Correct Answer is C
Explanation
Choice A reason: Administering alprazolam 0.5 mg PO is not the first action that the nurse should take. Alprazolam is a benzodiazepine that can be used to treat anxiety or insomnia, but it is not a priority intervention for a mother who has experienced a stillbirth. The nurse should assess the mother's emotional and physical needs before giving any medication.
Choice B reason: Contacting the health care facility's clergy is not the first action that the nurse should take. The nurse should respect the mother's spiritual and cultural beliefs and preferences, but not assume that she wants or needs the clergy's presence. The nurse should ask the mother if she would like to have any spiritual support or counseling.
Choice C reason: Offering the mother private time with the newborn is the first action that the nurse should take. This is a sensitive and compassionate way to acknowledge the mother's loss and grief, and to facilitate bonding and closure. The nurse should provide the mother with a quiet and comfortable environment, and allow her to hold, touch, and talk to the newborn as long as she wishes.
Choice D reason: Assisting the client with transferring to the gynecology unit is not the first action that the nurse should take. The nurse should not rush the mother to leave the labor and delivery unit, as this may increase her sense of isolation and abandonment. The nurse should allow the mother to stay in the same room until she is ready to move, and provide her with emotional and physical support during the transition.
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