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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: With type 2 diabetes, insulin secretion is decreased, and insulin resistance is increased. This means that the pancreas does not produce enough insulin, and the cells of the body do not respond well to the insulin that is available. Insulin is a hormone that helps the body use glucose (sugar) for energy. Without enough insulin or with insulin resistance, glucose builds up in the blood, leading to high blood sugar levels and various complications.
Choice B rationale: This statement describes Type 1 diabetes, where the immune system destroys insulin-producing cells.
Choice C rationale: This describes type 1 diabetes, not type 2 diabetes. People with type 2 diabetes may or may not need to take insulin, depending on how well they can control their blood sugar levels with diet, exercise, and oral medications.
Choice D rationale: This refers to pancreatitis, which is a condition where the pancreas becomes inflamed due to infection, injury, or alcohol abuse. Pancreatitis can cause
severe abdominal pain, nausea, vomiting, fever, and elevated levels of pancreatic enzymes in the blood.
Correct Answer is B
Explanation
Choice A rationale: While joint deformities are concerning in RA, the immediate attention would be required for an acute, red, hot, swollen joint which could indicate an active inflammatory process.
Choice B rationale: Redness, heat, and swelling in a joint are signs of an acute flare in rheumatoid arthritis and might require urgent intervention to manage the inflammation.
Choice C rationale: Puffy-looking areas behind the knee might indicate joint involvement but might not require immediate attention as much as an acutely inflamed joint.
Choice D rationale: Jaw pain while eating can be a symptom of TMJ involvement in RA, but an acutely inflamed joint would generally take precedence.
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