Cardiac monitoring is initiated for a patient with diabetic ketoacidosis. The nurse determines that this measure is important to identify:
Electrocardiographic (ECG) changes and dysrhythmias related to hypokalemia.
The presence of hypovolemic shock related to osmotic diuresis.
Cardiovascular collapse resulting from the effects of hyperglycemia.
Fluid overload resulting from aggressive fluid replacement.
The Correct Answer is A
Electrocardiographic (ECG) changes and dysrhythmias related to hypokalemia are the main reasons for initiating cardiac monitoring in patients with diabetic ketoacidosis. In diabetic ketoacidosis, insulin deficiency causes the body to break down fat for energy, leading to the production of ketones and resulting in metabolic acidosis. In addition, glucose and potassium are lost in the urine due to osmotic diuresis. Hypokalemia can cause ECG changes and dysrhythmias, which can be life-threatening.
Hypokalemia is a common complication of DKA and can lead to ECG changes such as ST-segment depression, T-wave inversion, and U waves².
Hypovolemic shock related to osmotic diuresis is an important consideration in the management of diabetic ketoacidosis, but it is not the primary reason for initiating cardiac monitoring.
Cardiovascular collapse resulting from the effects of hyperglycemia is not a common complication of diabetic ketoacidosis, and it is not the primary reason for initiating cardiac monitoring.
Fluid overload resulting from aggressive fluid replacement is a potential complication of diabetic ketoacidosis, but it is not the primary reason for initiating cardiac monitoring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Excess fluid volume related to intake greater than output would be the most appropriate nursing diagnosis for a patient with symptoms of DI (diabetes insipidus). This condition results in excessive urine output and, as a consequence, can lead to dehydration and electrolyte imbalances. Therefore, monitoring and managing fluid volume is a priority for patients with DI.
Risk for impaired skin integrity related to generalized edema is more commonly associated with conditions that cause fluid retention such as heart failure, liver failure, or kidney disease, rather than DI.
Activity intolerance related to muscle cramps and weakness is a possible nursing diagnosis for patients with conditions that affect muscle function, such as muscular dystrophy or multiple sclerosis, but not specifically for DI.
Insomnia related to waking at night to void is more commonly associated with urinary frequency or nocturia due to conditions such as urinary tract infections or benign prostatic hyperplasia, but not specifically for DI.
Correct Answer is B
Explanation
Furosemide is a loop diuretic that works by blocking the reabsorption of sodium and chloride in the ascending loop of Henle in the kidney, leading to increased urine output. However, this medication can also cause potassium loss through increased urinary excretion, which can lead to hypokalemia (low potassium level). Hypokalemia can cause confusion, weakness, and other neurological symptoms.
The normal range for serum potassium is 3.5 to 5.0 mEq/L. A potassium level of 2.9 mEq/L is below the normal range and is considered hypokalemic. Therefore, the nurse should correlate the client's confusion with the low potassium level and notify the healthcare provider to adjust the medication or provide potassium supplements if indicated.
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