A nurse is caring for a client who has diabetic ketoacidosis secondary to an infection. Which of the following prescriptions is the highest priority?
Obtain blood for culture and sensitivity.
Initiate IV infusion of regular insulin.
Initiate 0.9% sodium chloride 1,000 mL IV at 500 mL/hr.
Insert an indwelling urinary catheter.
The Correct Answer is B
A) Obtain blood for culture and sensitivity: While identifying the infection is important for treatment, it does not address the immediate metabolic crisis of diabetic ketoacidosis (DKA). This action is essential but secondary to stabilizing the client's current condition.
B) Initiate IV infusion of regular insulin: Administering insulin is critical in the management of DKA, as it helps to reduce blood glucose levels and halt the production of ketones, which are responsible for the acidosis. This intervention is vital for quickly correcting the metabolic derangement and stabilizing the patient.
C) Initiate 0.9% sodium chloride 1,000 mL IV at 500 mL/hr: While fluid replacement is important in the management of DKA to address dehydration and electrolyte imbalances, it is still not as immediately life-saving as starting insulin therapy. Fluid resuscitation typically follows the administration of insulin.
D) Insert an indwelling urinary catheter: This may be necessary for monitoring urine output and assessing kidney function, but it is not a priority intervention when addressing the acute complications of DKA. Insulin administration takes precedence in the immediate management plan.
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Correct Answer is A
Explanation
A) Remove one of the weights: This is the appropriate action. If the weights are resting on the floor, it indicates that the traction is ineffective, and removing one weight may be necessary to restore proper traction. However, the nurse should first verify the prescribed amount of weight with the healthcare provider before making adjustments.
B) Pull the client up in bed: While it may be necessary to reposition the client, pulling them up in bed does not address the issue of the weights resting on the floor and could potentially cause discomfort or injury.
C) Increase the elevation of the affected extremity: While elevating the extremity may be beneficial for swelling or comfort, it does not resolve the issue of ineffective traction caused by the weights on the floor.
D) Tie knots in the ropes near the pulleys to shorten them: This action is inappropriate. Tying knots in the ropes could interfere with the proper function of the traction system and is not a safe or effective solution to the problem.
Correct Answer is C
Explanation
A) Respiratory rate 10/min: A respiratory rate of 10 breaths per minute indicates bradypnea, which may be concerning. However, this finding is not directly associated with metoprolol. Metoprolol primarily affects heart rate and blood pressure, making this less relevant in identifying an adverse effect of the medication.
B) Blood pressure 138/76 mm Hg: This blood pressure reading is within the normal range for most individuals. While metoprolol can lower blood pressure, this value does not indicate an adverse effect, as it shows adequate control rather than a concerning reaction.
C) Heart rate 48/min: A heart rate of 48 beats per minute indicates bradycardia, a known adverse effect of beta-blockers like metoprolol. In patients with heart failure, this can lead to insufficient cardiac output and may require intervention. Thus, this finding is critical and should be addressed immediately.
D) Temperature 36.3° C (97.3° F): This temperature is within the normal range and does not indicate an adverse effect related to metoprolol. While monitoring temperature is important, it is not a direct concern regarding the use of this medication.