The nurse is caring for a client admitted with diabetic ketoacidosis (DKA). Which intervention is most important for the nurse to include in the client's plan of care?
Strict intake and output.
Maintain a large bore IV.
Keep NPO except for ice.
Monitor laboratory values
The Correct Answer is D
Choice A: Strict intake and output monitoring is important in the care of clients with DKA, but it is not the most critical intervention among the choices provided.
Choice B: Maintaining a large bore intravenous (IV) is important for providing the necessary fluids and medications in DKA treatment, but it is not the highest priority.
Choice C: Keeping the client NPO except for ice may be part of the initial management of DKA to address fluid and electrolyte imbalances, but it is not the most important intervention in the client's overall plan of care.
Choice D: Monitoring laboratory values is the most important intervention for a client with diabetic ketoacidosis (DKA). Regular assessment of blood glucose levels, electrolytes (e.g., potassium, sodium), and arterial blood gases (ABGs) is crucial for guiding treatment and ensuring that DKA is resolving. Adjustments to insulin and fluids are based on these laboratory values to prevent complications such as cerebral edema or cardiac arrhythmias.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A,B,D,C
Explanation
Choice A: Retracting the needle into the syringe should be done before safely disposing of the syringe.
Choice B: Placing the syringe in a puncture-resistant container is the second step to ensure safe disposal of sharp objects.
Choice C: Applying an adhesive bandage over the injection site is the final step to address the bleeding and protect the site.
Choice D: Removing disposable exam gloves is the next step to prevent any contamination.
Correct Answer is C
Explanation
Choice A: Bread is generally considered a suitable food choice for individuals with cholelithiasis and is not typically associated with exacerbating symptoms or gallstone formation.
Choice B: Beef broth is a liquid and does not contain the same types of fats and cholesterol that can contribute to gallstone formation. It is not typically a concern for individuals with cholelithiasis.
Choice C: Ketchup is often high in sugar and can be made with vinegar, which may exacerbate symptoms in some individuals with cholelithiasis. It is advisable to omit or limit foods high in sugar and vinegar-based condiments.
Choice D: Ice cream, while high in fat, is generally tolerated by most individuals with cholelithiasis unless they experience specific dietary sensitivities. It is not typically recommended to omit ice cream from the diet unless advised by a healthcare provider.
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