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) Place the client's bed at the lowest height: This intervention is essential for safety. Lowering the bed height minimizes the risk of injury from falls, which is particularly important for clients with dementia who may experience disorientation or difficulty with mobility.
B) Request a prescription for a nightly sedative: While managing anxiety and agitation can be important, using sedatives in clients with dementia can lead to increased confusion, falls, and other complications. Non-pharmacological interventions are usually preferred.
C) Assist the client with toileting at least once every 4 hr: While promoting regular toileting is important, the frequency should be tailored to the individual's needs. Clients with dementia may require more frequent assistance based on their understanding and ability to communicate their needs.
D) Turn off all lights in the client's room at night: This could lead to disorientation and fear in clients with dementia. It's usually more beneficial to provide soft lighting to create a calming environment and reduce the risk of falls.
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.