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) Decreased anxiety: Morphine is an opioid analgesic that not only alleviates pain but also has anxiolytic properties, helping to reduce anxiety and promote a sense of well-being. In the context of acute heart failure, clients often experience anxiety due to the sensation of breathlessness and overall distress. Therefore, a noticeable decrease in anxiety levels indicates that the morphine is providing therapeutic relief and contributing positively to the client's emotional state.
B) Emesis of 250 mL: While nausea and vomiting can occur with morphine administration, emesis is generally considered an adverse effect rather than an indication of the medication's effectiveness. In fact, significant vomiting can lead to further complications, such as dehydration or electrolyte imbalances, and may require intervention. Therefore, emesis does not reflect the intended therapeutic outcomes of morphine.
C) Increased respiratory rate to 26/min: An increased respiratory rate may signal distress or inadequate ventilation, which can be concerning in a client with acute heart failure. While morphine can cause respiratory depression in some cases, an elevated respiratory rate may indicate that the client is still experiencing discomfort or hypoxia, suggesting that the medication may not have been effective in alleviating their symptoms.
D) Decreased urinary output: Decreased urinary output can be a sign of renal impairment or fluid overload, which may be exacerbated by heart failure rather than an indication of morphine's effectiveness. In the setting of acute heart failure, monitoring urinary output is essential, but a reduction does not reflect the success of morphine therapy and may warrant further evaluation and intervention.
Correct Answer is C
Explanation
A) Blistering at the site: Blistering is typically associated with partial-thickness burns rather than full-thickness burns. Full-thickness burns destroy both the epidermis and dermis, which usually do not present with blisters.
B) Epithelialization at the site: Epithelialization is a healing process that occurs after the burn site begins to heal. Since this client has sustained major full-thickness burns only 12 hours ago, epithelialization is not expected at this early stage.
C) Edema at the site: Edema is expected in the early stages following a major burn injury due to the inflammatory response and fluid shift that occurs. This finding aligns with the body's response to trauma and is common within the first 24 hours after a burn.
D) Severe pain at the site: Full-thickness burns typically have less pain at the site compared to partial-thickness burns because the nerve endings in the skin are destroyed. While there may be pain in surrounding areas or in partial-thickness areas, the full-thickness burn itself is often painless.