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 C
Explanation
A) Monitor the client's vital signs once every hour: After a cardiac catheterization, it is crucial to monitor vital signs more frequently than every hour. The nurse should assess vital signs every 15 minutes for the first hour, then every 30 minutes for the next two hours, and
then according to the facility's protocol, to quickly identify any complications.
B) Elevate the head of the client's bed to a 45° angle: Elevating the head of the bed to a 45° angle is generally not recommended immediately following cardiac catheterization through the femoral artery. The client should remain flat or with the head elevated no more than 30 degrees to reduce the risk of bleeding from the access site.
C) Instruct the client not to bend the affected leg: This is the most appropriate action. Keeping the affected leg straight is essential to prevent complications such as bleeding or hematoma formation at the catheter insertion site. The client should be instructed to avoid bending or flexing the leg for a specified period, usually several hours post-procedure.
D) Restrict the client's fluid intake: Restricting fluid intake is not necessary after cardiac catheterization. In fact, adequate hydration is often encouraged to help flush the contrast dye from the system and maintain kidney function, provided there are no contraindications.
Correct Answer is D
Explanation
A) "I should use both hands to recap a needle." This statement reflects unsafe practice. The correct method is to avoid recapping needles whenever possible, and if it is necessary, to use a one-handed technique to minimize the risk of a needlestick injury.
B) "Sterile gloves are required when administering an IM injection." This statement is incorrect because sterile gloves are not typically required for intramuscular (IM) injections. Clean gloves are sufficient, as the injection site does not require a sterile field unless there is a specific reason, such as a compromised immune system.
C) "I should wear a gown to remove linens from a client's bed." While wearing a gown may be necessary in certain situations (such as when there is a risk of exposure to blood or body fluids), it is not universally required for simply removing linens. The decision to wear a gown should be based on the assessment of the risk involved.
D) "I should wear goggles when irrigating a wound." This statement demonstrates an understanding of personal protective equipment use. Goggles or face shields are recommended to protect the eyes from potential splashes of blood or other body fluids during wound irrigation, which is a procedure that can pose a risk of exposure.