Exhibits

Which of the following 3 provider prescriptions does the nurse anticipate?

. 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.

D. An oral airway is a device used to maintain a patent airway by preventing the tongue from obstructing the throat. It can be useful during or after a seizure to ensure the client can breathe effectively and to prevent airway obstruction due to tongue relaxation or loss of muscle tone.

A Wrist restraints are used to immobilize a client's wrists and are not typically indicated for seizure management. Restraining a client during a seizure can increase the risk of injury and hinder appropriate assessment and care

B. Nasogastric (NG) tubes are used for enteral feeding, medication administration, or gastric decompression. They are not directly related to managing seizures and are not typically required during or after a seizure episode. Therefore, an NG tube is not necessary in the client's room for seizure management.

C. Tongue blades are used to depress the tongue for examination of the mouth and throat, but they are not recommended during or immediately after a seizure. There is a common misconception that placing a tongue blade in the mouth prevents the tongue from being bitten during a seizure, but this can actually cause more harm, such as injury to the teeth or gums, during involuntary movements.