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 C
Explanation
Choice A reason: Improved hydration is not a specific indicator of the effectiveness of the treatment for acute laryngotracheobronchitis. Hydration status should be monitored for any child with a respiratory infection, but it does not reflect the severity of the airway inflammation.
Choice B reason: Decreased temperature is not a specific indicator of the effectiveness of the treatment for acute laryngotracheobronchitis. Fever may or may not be present in this condition, and it does not correlate with the degree of airway obstruction.
Choice C reason: Decreased stridor is a specific indicator of the effectiveness of the treatment for acute laryngotracheobronchitis. Stridor is a high-pitched sound caused by turbulent airflow through a narrowed upper airway. It indicates a significant obstruction that can compromise breathing. A reduction in stridor means that the airway inflammation has subsided and the child can breathe more easily.
Choice D reason: Barking cough is not a specific indicator of the effectiveness of the treatment for acute laryngotracheobronchitis. Barking cough is a characteristic symptom of this condition, caused by the swelling of the vocal cords. It may persist for several days after the acute episode, even when the child is improving.
Correct Answer is B
Explanation
Choice A reason: A protective environment is a type of isolation precaution that is used for patients who are immunocompromised and at high risk of infection from environmental sources, such as fungi or bacteria. It involves using a private room with positive air pressure, high-efficiency particulate air (HEPA) filtration, and strict hand hygiene. It is not indicated for patients who have measles, as they are the source of infection, not the susceptible host.
Choice B reason: Airborne is a type of isolation precaution that is used for patients who have diseases that are transmitted by small droplets that can remain suspended in the air and travel over long distances, such as tuberculosis, chickenpox, or measles. It involves using a private room with negative air pressure, HEPA filtration, and respiratory protection for health care workers and visitors. It is the appropriate isolation precaution for patients who have measles, as it prevents the spread of the virus to others.
Choice C reason: Contact is a type of isolation precaution that is used for patients who have diseases that are transmitted by direct or indirect contact with the patient or their environment, such as Clostridioides difficile, scabies, or impetigo. It involves using a private room or cohorting with similar patients, wearing gloves and gowns, and using dedicated equipment. It is not indicated for patients who have measles, as the disease is not spread by contact.
Choice D reason: Droplet is a type of isolation precaution that is used for patients who have diseases that are transmitted by large droplets that are generated by coughing, sneezing, or talking, such as influenza, pertussis, or meningitis. It involves using a private room or cohorting with similar patients, wearing a surgical mask, and maintaining a distance of at least 3 feet from the patient. It is not indicated for patients who have measles, as the disease is spread by airborne transmission.
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