The nurse is caring for a client with diabetic ketoacidosis (DKA) receiving intravenous (IV) regular insulin. The most recent potassium was 2.9 mEq/L. The nurse should take which priority action:

Assess the client urine output (UOP)

Obtain a 12-lead electrocardiogram (ECG)

Notify the primary healthcare provider (PMHCP)

Stop the regular insulin infusion

Answer and Explanation

The Correct Answer is C

Choice A rationale: Assessing the UOP is important, but not as urgent as correcting the potassium imbalance.

Choice B rationale: Obtaining a 12-lead ECG can help monitor the cardiac status, but it does not address the cause of the problem.

Choice C rationale: The PMHCP can order potassium replacement to prevent cardiac arrhythmias and other adverse effects of low potassium levels.

Choice D rationale: Stopping the regular insulin infusion can worsen the DKA and increase the risk of cerebral edema and coma.

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Correct Answer is B

Explanation

Choice A rationale: This is not accurate since the manifestations of facial nerve paralysis are observed on the contralateral side which in this case is the left side of the face hence the right facial nerve is paralyzed.

Choice B rationale: Facial nerve paralysis cause symptoms such as drooping of the eyelid, cheek or mouth as depicted in the above picture. The right facial nerve is paralyzed since the nerve innervates the contralateral side hence the effects are demonstrated on the

left side of the face.

Choice C rationale: trigeminal nerve paralysis causes symptoms such as weakness in muscles of mastication, altered sensation over the face and tongue, and hearing impairment and not the symptoms depicted above.

Choice D rationale: trigeminal nerve paralysis causes symptoms such as weakness in muscles of mastication, altered sensation over the face and tongue, and hearing impairment and not the symptoms depicted above.

A. A 58-year-old client with gastrointestinal reflux disease B. A 65-year-old client with mild emphysema C. A 72-year-old client with hyperthyroidism D. A 48-year-old client with hypertension

Correct Answer is D

Explanation

Choice A rationale: Gastrointestinal reflux disease is not typically a contraindication for sumatriptan.

Choice B rationale: Mild emphysema is not typically a contraindication for sumatriptan.

Choice C rationale: Hyperthyroidism is not typically a contraindication for sumatriptan.

Choice D rationale: Sumatriptan, a medication used for migraines, may elevate blood pressure, so it would be questionable for a client with hypertension.

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The nurse is caring for a client with diabetic ketoacidosis (DKA) receiving intravenous (IV) regular insulin. The most recent potassium was 2.9 mEq/L. The nurse should take which priority action:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse exploring cranial nerves function and observes the following reaction: The nurse documents that the client has a:

Correct Answer is B

Explanation

For which client with severe migraine headaches would the nurse question an order for sumatriptan?

Correct Answer is D

Explanation

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