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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is D
Explanation
A) "I've been having problems with bladder control.": While bladder control issues can be associated with certain neurological conditions, they are not specific to myasthenia gravis. This statement may indicate a need for further assessment but does not directly suggest a need for occupational therapy.
B) "I have difficulty swallowing food.": Dysphagia is a common concern in myasthenia gravis, but this statement may warrant a referral to a speech-language pathologist rather than occupational therapy. Addressing swallowing difficulties typically falls within the scope of speech therapy.
C) "I would rather be in a wheelchair than use a walker to get around.": This statement reflects a personal preference for mobility aids. While it could indicate a need for assistance in mobility, it does not specifically point to a need for occupational therapy services.
D) "I have a hard time with brushing my hair.": This statement clearly indicates difficulty with activities of daily living (ADLs) due to muscle weakness associated with myasthenia gravis. A referral for occupational therapy would be appropriate to help the client develop strategies and adaptive techniques to manage daily tasks more effectively.
Correct Answer is B
Explanation
A) "Clean the spacer daily with cold water": While it is important to clean the spacer regularly to prevent bacterial growth, the recommendation is usually to clean it weekly with warm, soapy water rather than daily with cold water. This detail is essential for effective use but not the most critical point during initial teaching.
B) "Hold your breath for 10 seconds once you inhale": This statement is key to ensuring effective medication delivery. Holding the breath for about 10 seconds allows the medication to settle in the lungs, maximizing its therapeutic effects. This information is crucial for the client to understand the proper technique for using the inhaler with a spacer.
C) "Wait 30 seconds between puffs": While it is advisable to wait for a brief period between puffs to allow the first dose to be effective, the recommended wait time is generally around 1 minute, particularly if using a different medication or if instructed by the healthcare provider. Therefore, stating 30 seconds may be misleading.
D) "The spacer should make a whistling sound as you inhale": A whistling sound during inhalation may indicate that the spacer is being used incorrectly or that the client is inhaling too forcefully. The absence of a whistling sound is often a sign of proper technique. Therefore, this statement is misleading and not appropriate teaching for effective inhaler use.