Exhibits
Which of the following 3 provider prescriptions does the nurse anticipate?
Regular insulin 20 units subcutaneously
Potassium chloride 20 mEq/L intravenous PRN potassium less than 5.0 mEq/L
Initiate cardiac monitoring
0.9% sodium chloride at 15 ml/kg/hr for 1 hr and then reduce to 10 ml/kg/hr
Regular insulin continuous intravenous infusion, titrate per diabetic ketoacidosis (DKA) protocol once potassium is greater than 3.3 mEq/L
Dextrose 5% in water (DSW) intravenous at 5 ml/kg/hr for 4 hr
Blood glucose checks every 4 hr
Insert indwelling urinary catheter
Correct Answer : B,D,E
. Potassium chloride 20 mEq/L intravenous PRN potassium less than 5.0 mEq/L
The client's potassium level is slightly elevated at 5.5 mEq/L. Potassium replacement may be necessary if the level drops below 5.0 mEq/L, which is within the anticipated range for the nurse's actions.
D.0.9% sodium chloride at 15 ml/kg/hr for 1 hr and then reduce to 10 ml/kg/hr
This prescription addresses the need for fluid resuscitation to correct dehydration and electrolyte imbalances often seen in DKA. The client's initial blood pressure of 96/65 mm Hg suggests some degree of dehydration, further supporting the use of isotonic saline.
E.Regular insulin continuous infusion, titrate per diabetic ketoacidosis (DKA) protocol once potassium is greater than 3.3 mEq/L
This prescription aligns with the client's presentation of severe hyperglycemia (468 mg/dL) and acidosis (pH 7.30), indicating diabetic ketoacidosis (DKA). Insulin infusion is crucial for lowering blood glucose levels and correcting acidosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A Canola oil is a healthier choice compared to saturated fats like butter or coconut oil because it is lower in saturated fat and high in unsaturated fats (monounsaturated and polyunsaturated fats). Using canola oil can help lower LDL (bad) cholesterol levels and reduce the risk of heart disease.
B. Canned vegetables often contain added sodium as a preservative, which can contribute to hypertension (high blood pressure), a risk factor for cardiovascular disease. Therefore, increasing intake
of canned vegetables is not recommended for someone with cardiovascular disease unless they are choosing low-sodium or no-added-salt varieties.
C. Limiting portions of meat helps reduce intake of saturated fats, which can raise LDL cholesterol levels and increase the risk of heart disease. A portion size of 8 ounces is appropriate as part of a heart-healthy diet that emphasizes lean proteins and plant-based sources of protein.
D. Whole milk is higher in saturated fat compared to low-fat or skim milk. Consuming saturated fats increases LDL cholesterol levels, which can contribute to cardiovascular disease. Therefore, drinking whole milk is not recommended for someone with cardiovascular disease who should focus on reducing saturated fat intake.
Correct Answer is A
Explanation
A A change in level of consciousness (LOC), such as confusion, lethargy, or loss of consciousness, can indicate worsening neurological status. It reflects impaired brain function due to increased pressure on brain tissues.
B. Pupillary changes, such as dilation or asymmetry, can occur due to pressure on the oculomotor nerve (cranial nerve III). Pupillary dilation can be a sign of increased ICP but typically occurs after other neurological changes.
C. Decorticate posturing indicates significant neurological impairment but typically appears after alterations in consciousness.
D. Cheyne-Stokes respirations indicate brainstem involvement and impaired respiratory control but are generally seen later in the progression of neurological deterioration.
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