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 D
Explanation
Choice A reason: Using a 20 gauge needle is not the best action, as it is too large for a preschooler's deltoid muscle. A 20 gauge needle has a diameter of 0.9 mm, which may cause more pain and tissue damage. A smaller gauge needle, such as a 23 or 25 gauge, is recommended for intramuscular injections in children.
Choice B reason: Inserting the needle just below the acromion process is not the best action, as it may not reach the deltoid muscle. The acromion process is the bony prominence at the top of the shoulder. The deltoid muscle is located on the lateral aspect of the upper arm, about two finger widths below the acromion process. The nurse should palpate the acromion process and measure the distance to the injection site.
Choice C reason: Inserting the needle at a 15 degree angle is not the best action, as it may not penetrate the muscle tissue. A 15 degree angle is used for intradermal injections, which are given into the dermis, the layer of skin below the epidermis. Intramuscular injections are given into the muscle tissue, which requires a 90 degree angle. The nurse should hold the syringe perpendicular to the skin and insert the needle quickly and firmly.
Choice D reason: Using a 1.8 mm (0.5 in) needle is the best action, as it is the appropriate length for a preschooler's deltoid muscle. The length of the needle should be based on the child's age, weight, and muscle mass. A 1.8 mm (0.5 in) needle is suitable for children who weigh less than 12 kg (26 lb). A longer needle, such as a 2.5 mm (1 in) needle, may be used for children who weigh more than 12 kg (26 lb).
Correct Answer is D
Explanation
Choice A reason: This is not a statement that indicates a need for further teaching. The client is doing wheelchair exercises while watching TV, which is a good way to maintain physical activity and prevent muscle atrophy and contractures. The nurse should praise the client for this behavior and encourage them to continue.
Choice B reason: This is not a statement that indicates a need for further teaching. The client is carrying a water bottle with them and drinking a lot of water, which is a good way to prevent dehydration and urinary tract infections. The nurse should praise the client for this behavior and remind them to drink at least 2 liters of water per day.
Choice C reason: This is not a statement that indicates a need for further teaching. The client is using a suppository every night to have a bowel movement, which is a common method of managing bowel dysfunction in clients with spina bifida. The nurse should ask the client about their bowel routine and provide any additional education or support as needed.
Choice D reason: This is a statement that indicates a need for further teaching. The client is only catheterizing themselves twice every day, which is not enough to prevent urinary retention and infection. The nurse should explain to the client that they need to catheterize themselves at least every 4 to 6 hours, or as prescribed by the provider. The nurse should also demonstrate the proper technique and hygiene for catheterization and assess the client's ability to perform it.
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