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) NG tube: A nasogastric (NG) tube is not typically required for a client with a seizure
disorder unless there are specific feeding or medication administration needs post-seizure. It is not standard equipment for seizure management.
B) Wrist restraints: While restraints may be used in some situations to prevent injury, they are not routinely placed in a seizure patient's room and could increase the risk of harm during a seizure. It is generally best to ensure a safe environment without restraints.
C) Oral airway: Having an oral airway available in the client's room is essential for managing airway patency during or after a seizure. It can help to maintain an open airway, especially if the client becomes unresponsive or is at risk of aspiration.
D) Tongue blade: Using a tongue blade to hold the mouth open during a seizure is not recommended, as it can cause injury to the client or the nurse. It's a common myth that it should be used to prevent biting the tongue, but doing so can lead to more harm than good
Correct Answer is D
Explanation
A) Acute loss of alveolar elasticity: While loss of alveolar elasticity can impact overall lung function, it is more associated with chronic conditions like emphysema rather than acute asthma attacks. In asthma, the primary issue is related to airway obstruction and inflammation rather than alveolar elasticity.
B) Decreased responsiveness of airways to allergens: During an acute asthma attack, the airways typically exhibit increased sensitivity and responsiveness to allergens and irritants, not decreased responsiveness. This heightened response contributes to the bronchoconstriction and inflammation seen in asthma.
C) Suppressed bronchiolar inflammatory response: In an asthma attack, there is actually an exaggerated inflammatory response in the bronchioles. This inflammation leads to swelling, mucus production, and bronchoconstriction, which contribute to the difficulty in breathing.
D) Inability to exhale retained carbon dioxide: This is a significant factor during an acute asthma attack. The bronchoconstriction and airway obstruction make it difficult for the client to exhale fully, leading to the retention of carbon dioxide. This can cause respiratory acidosis and worsen the client's condition, highlighting the urgency of treatment.