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Patient Data.

Exhibits

What are three goals of therapy for this client? Select three that apply.

Correct electrolytes that are out of normal range.

Promote oxygenation to tissues.

Prevent hyperventilation.

Reverse dehydration.

Replace insulin.

Provide respiratory support.

Answer and Explanation

Correct Answer : A,D,E

Choice A rationale:

Correcting electrolytes that are out of normal range is a crucial goal of therapy for this client. In diabetic ketoacidosis (DKA), the body’s cells are unable to use glucose for energy due to a lack of insulin. This leads to the breakdown of fat for energy, producing ketones as a by-product. Ketones are acidic and can cause the blood’s pH to decrease, leading to metabolic acidosis. This process also leads to an increased production and excretion of electrolytes such as potassium and sodium. Therefore, correcting these electrolyte imbalances is a key goal of therapy.

Choice B rationale:

While promoting oxygenation to tissues is generally important in critical care, it is not a specific goal in the management of DKA. The primary issues in DKA are metabolic in nature, including hyperglycemia, ketosis, and acidosis.

Choice C rationale:

Preventing hyperventilation is not a specific goal in the management of DKA. Hyperventilation in DKA is a compensatory mechanism for metabolic acidosis (Kussmaul breathing). The body tries to expel more carbon dioxide to reduce the acidity of the blood.

Choice D rationale:

Reversing dehydration is another important goal of therapy for this client. In DKA, high blood glucose levels lead to osmotic diuresis, where water is drawn into the urine from the blood, leading to dehydration. This can cause hypotension and reduced tissue perfusion. Therefore, reversing dehydration through fluid replacement is a key part of treatment.

Choice E rationale:

Replacing insulin is a fundamental goal of therapy for this client. Insulin deficiency is the primary cause of DKA. Insulin allows glucose to enter cells where it can be used for energy, preventing the breakdown of fat for energy and the subsequent production of ketones.

Choice F rationale:

Providing respiratory support may be necessary in severe cases of DKA where the patient’s compensatory respiratory efforts are insufficient to maintain adequate gas exchange. However, it is not one of the primary goals of therapy in DKA management.

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Correct Answer is C

Explanation

Choice A rationale:

The nurse should respect the client's autonomy and right to make decisions about her own care. It is essential to honor the client's refusal of further treatment, and the nurse should communicate this to the family. In this situation, the client has the capacity to make her own decisions, and her wishes should be respected.

Choice B rationale:

Attempting to persuade the client to participate in the clinical trial for one month is not an appropriate approach. It disregards the client's autonomy and her right to refuse treatment. It's essential to respect the client's decision, and trying to convince her against her will is ethically and legally inappropriate.

Choice D rationale:

While it's important to ensure that the client fully understands the implications of her decision, doing so in front of her children may create additional pressure or discomfort for the client. The best approach is to have a private conversation with the client to assess her understanding and provide information or support as needed.

A. Ask the mother if any visitors were expected to arrive. B. Match ID bands of all infants and mothers on the unit. C. Determine if the newborn is in the nursery. D. Activate the lockdown procedure.

Correct Answer is D

Explanation

The correct answer is D. Activate the lockdown procedure.

Choice A rationale:

Asking the mother about expected visitors is important for later investigation, but it does not address the immediate concern of a potentially missing infant and delays necessary security measures.

Choice B rationale:

Matching ID bands is an essential step in verifying the identity of infants and mothers, but it should follow initial actions to secure the area and prevent possible abduction.

Choice C rationale:

Determining if the newborn is in the nursery is a logical step but not the first priority. The immediate action should be to secure the unit to prevent any potential abductor from leaving.

Choice D rationale:

Activating the lockdown procedure is the first priority to ensure the safety of the infant and prevent any unauthorized individuals from leaving the facility. This step is crucial to quickly address the situation and prevent potential abduction.

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Patient Data. Exhibits What are three goals of therapy for this client? Select three that apply.

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. Which action should the nurse take first?

Correct Answer is D

Explanation

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Patient Data.

Exhibits

What are three goals of therapy for this client? Select three that apply.