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 B
Explanation
A) Increased urine output: This finding is more commonly associated with hyperglycemia and diabetic ketoacidosis, where the body attempts to excrete excess glucose through urine. In hypoglycemia, urine output is typically not increased.
B) Cold, clammy skin: This is a classic symptom of hypoglycemia. As blood sugar levels drop, the body releases adrenaline, which can cause sweating and result in cold, clammy skin. This finding directly supports the suspicion of hypoglycemia.
C) Acetone breath: This is associated with diabetic ketoacidosis, a complication of uncontrolled hyperglycemia. The presence of acetone on the breath indicates the breakdown of fat for energy, not a low blood sugar state.
D) Kussmaul respirations: These deep, labored breaths are typically seen in metabolic acidosis, particularly in diabetic ketoacidosis. They are not indicative of hypoglycemia.
Correct Answer is B
Explanation
A)"Iwilltrytolimitfoodsthatcontainsalt.":Limitingsaltintakeisimportantformanagingheartfailurebutdoesn'tspecificallyaddresstheadverseeffectsoffurosemide.Thisdiureticcancauseelectrolyteimbalances,butsaltrestrictionismorerelatedtooverallheartfailuremanagement.
B)"I'mgoingtoincludemorecantaloupeinmydiet.":Furosemidecancausepotassiumdepletion,andcantaloupeishighinpotassium.Increasingpotassium-richfoodsinthediethelpscounteractthisadverseeffect,indicatingtheclientunderstandstheneedtomaintainelectrolytebalance.
C)"IwillcheckmypulsebeforeItakethemedication.":Whilemonitoringheartratecanbeusefulinmanagingheartconditions,itisnotspecifictotheprimaryadverseeffectsoffurosemide.Thekeyconcernwiththismedicationisitsimpactonelectrolytesandfluidbalance.
D)"I'llcheckmybloodpressuresoitdoesn'tgettoohigh.":Furosemidetypicallylowersbloodpressure,sotheconcernwouldbehypotension(lowbloodpressure)ratherthanhypertension(highbloodpressure).Thisstatementdoesn’treflectanunderstandingoffurosemide’sprimaryadverseeffects.