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 C
Explanation
Choice A rationale: Peptic ulcer disease doesn't typically present with ecchymosis around the umbilicus (Cullen's sign) or significantly elevated amylase and lipase levels.
Choice B rationale: Gastroenteritis is less likely given the specific symptoms, physical exam findings, and laboratory results indicating pancreatic involvement.
Choice C rationale: Acute pancreatitis fits the clinical picture with epigastric pain after heavy alcohol use, persistent nausea/vomiting, tenderness, and elevated amylase and lipase levels.
Choice D rationale: Diverticulitis typically presents with symptoms more localized to the lower abdomen and doesn't cause the characteristic findings seen in this scenario.
Correct Answer is D
Explanation
Choice A rationale: Asymmetric facial movement might be associated with damage to other cranial nerves, not specifically cranial nerve III.
Choice B rationale: Uvula deviation is a sign of damage to the glossopharyngeal (IX) and vagus (X) nerves, not cranial nerve III.
Choice C rationale: Anosmia, the loss of sense of smell, is not typically associated with cranial nerve III dysfunction.
Choice D rationale: Damage to cranial nerve III (oculomotor nerve) can lead to ptosis, the drooping of the eyelid.
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