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) Spironolactone: Spironolactone is a potassium-sparing diuretic often used in heart failure and hypertension management. It is not indicated for allergic reactions or hives and does not address the symptoms caused by IV contrast dye.
B) Metoclopramide: Metoclopramide is an antiemetic medication used to treat nausea and vomiting. It is not effective for treating allergic reactions or urticaria, so this option is not appropriate in this context.
C) Diphenhydramine: Diphenhydramine is an antihistamine that is commonly used to treat allergic reactions, including hives and urticaria. Administering diphenhydramine will help alleviate the symptoms related to the adverse reaction to the IV contrast dye, making it the most appropriate medication to administer in this situation.
D) Desmopressin: Desmopressin is used to treat conditions such as diabetes insipidus and certain bleeding disorders. It has no role in treating allergic reactions or hives, making it an inappropriate choice for this scenario.
Correct Answer is D
Explanation
A) Instruct the client to expect tingling in their extremities: Tingling in the extremities is not a common or expected outcome of a lumbar puncture. While some clients may experience mild discomfort, tingling could indicate nerve irritation or other complications that should be assessed.
B) Limit the client's fluid intake: After a lumbar puncture, clients are typically encouraged to increase their fluid intake to help replenish cerebrospinal fluid (CSF) and reduce the risk of headaches. Limiting fluid intake is not appropriate.
C) Measure blood glucose every 2 hr: Routine blood glucose monitoring is not indicated immediately following a lumbar puncture unless there is a specific concern or reason to do so. This action does not directly relate to the care needed post-procedure.
D) Instruct the client to lie flat: Lying flat is often recommended after a lumbar puncture to reduce the risk of post-puncture headache, which can occur due to changes in CSF pressure. This position helps promote healing and minimizes discomfort.