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 D
Explanation
A) Temperature of 37.9° C (100.2° F): A slight elevation in temperature can be common after surgery and may not indicate a serious issue. It should be monitored, but it is not immediately concerning.
B) Urine output 150 mL over 4 hr: While urine output is an important indicator of kidney function and overall perfusion, this output may still be acceptable depending on the client's overall fluid status and other factors. It does not necessarily require immediate reporting unless there are other concerning symptoms.
C) Bruising around the incisional site: Some bruising can be expected after surgery, particularly with arterial procedures. It should be monitored, but unless there are signs of excessive bleeding or hematoma formation, it is not typically an urgent concern.
D) Pallor in the affected extremity: This finding is critical and should be reported immediately. Pallor could indicate compromised blood flow to the extremity, which could be a sign of complications such as graft occlusion or inadequate perfusion. Prompt intervention may be necessary to prevent serious complications or tissue loss.
Correct Answer is A
Explanation
A) "Your breathing pattern causes this.": This statement accurately explains the phenomenon known as "tidaling." The rise and fall of fluid in the water-seal chamber is a normal response to the client’s breathing. As the client inhales, the negative pressure in the pleural space increases, causing the fluid level to rise, and it falls during exhalation. This indicates that the chest tube is functioning properly.
B) "This indicates a possible air leak.": An air leak would typically manifest as continuous bubbling in the water-seal chamber, not as tidaling. Tidaling is a normal finding, so this statement is misleading and does not accurately describe the situation.
C) "This means your lung is fully re-expanded.": While tidaling can be a sign of lung re-expansion, it does not definitively indicate that the lung is fully re-expanded. The presence of tidaling alone does not confirm complete re-expansion of the lung.
D) "Suction pressure that is too high causes this.": Suction pressure relates to the amount of suction applied to the drainage system, but it does not cause the normal rise and fall of fluid in the water-seal chamber. This statement is incorrect in the context of explaining the observed phenomenon.