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
Explanation
Choice A: The client's statement reflects an understanding of the DASH diet's emphasis on lean meats, nuts, and dried beans as protein sources, which aligns with the principles of the diet.
Choice B: The DASH diet encourages the consumption of more than 4 to 6 servings of fruits and vegetables daily.
Choice C: The DASH diet does not eliminate dairy-based products but recommends choosing low-fat or fat-free options.
Choice D: The DASH diet does not focus on gluten-free foods but rather on overall dietary patterns that promote heart-healthy eating.
Correct Answer is B
Explanation
Choice A: A platelet count of 135,000/mm3 is slightly below the lower end of the normal range, but it may not be considered critically low. It is not the highest priority finding among the choices provided.
Choice B: A blood urea nitrogen (BUN) level of 75 mg/dL is significantly elevated and outside the normal range. Elevated BUN can indicate kidney dysfunction or dehydration and should be reported promptly.
Choice C: Decreased deep tendon reflexes may be related to various factors, including medication effects, and may not be considered the highest priority finding unless it is associated with other concerning symptoms.
Choice D: Periodic nausea and vomiting can be common side effects of chemotherapy, but they may not be considered the highest priority finding unless they are severe, persistent, or associated with signs of dehydration or electrolyte imbalances.
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