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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

The operating room is a sterile environment, and it is critical to maintain a clean and controlled environment to reduce the risk of infection to the patient. The measures taken include maintaining positive air pressure, controlling temperature and humidity, filtering the air, using sterile surgical instruments, and limiting traffic in and out of the operating room. These measures help to prevent the spread of infectious agents that may be present in the operating room. While the other options (a, b, and d) may also be important considerations in the design of the operating room, preventing transmission of infection is the primary goal.

A. Provide three large meals a day. B. Observe stool characteristics. C. Evaluate intake and output. D. Monitor laboratory reports of electrolytes.

Correct Answer is A

Explanation

Clients with acute gastritis are recommended to eat smaller, frequent meals instead of three large meals. This helps to reduce the workload on the digestive system and allows the stomach to heal. Therefore, option A is not a suitable nursing intervention for a client with acute gastritis.

Options b, c, and d are all appropriate nursing interventions for a client with acute gastritis. Observing stool characteristics can help to identify any bleeding or inﬂammation in the gastrointestinal tract, evaluating intake and output can help to identify any ﬂuid imbalances, and monitoring laboratory reports of electrolytes can help to identify any imbalances that may occur because of vomiting or diarrhea.

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Cardiac monitoring is initiated for a patient with diabetic ketoacidosis. The nurse determines that this measure is important to identify:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The physical environment and traffic control measures of the operating room are designed primarily to:

Correct Answer is C

Explanation

A nurse is planning care for a client who has acute gastritis. Which of the following nursing interventions should NOT be included in the plan of care?

Correct Answer is A

Explanation

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