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The nurse evaluates the client who is being treated for DKA. Which finding indicates that the client is responding to the treatment plan?
- A. Eyes sunken and skin flushed
- B. Skin moist with rapid elastic recoil
- C. Serum potassium level is 3.3 mEq/L
- D. ABG results are pH 7.25, PaCO2 30, HCO3 17
Correct Answer: B
Rationale: Moist skin and good skin turgor indicate that dehydration secondary to hyperglycemia is resolving.
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How soon after administering the client's dose of regular insulin subcutaneously should the nurse assess for signs of hypoglycemia?
- A. 5 minutes later
- B. 30 minutes later
- C. 6 hours later
- D. 10 hours later
Correct Answer: B
Rationale: Regular insulin peaks around 2-4 hours, but early hypoglycemia can occur within 30 minutes, requiring assessment.
The nurse is caring for the client admitted in Addisonian crisis. Which medication, if prescribed, should the nurse plan to administer?
- A. Regular insulin
- B. Ketoconazole
- C. Sodium nitroprusside
- D. Hydrocortisone
Correct Answer: D
Rationale: Hydrocortisone is a corticosteroid used to replace deficient glucocorticoids in Addisonian crisis.
Which assessment data indicate the client diagnosed with diabetic ketoacidosis is responding to the medical treatment?
- A. The client has tented skin turgor and dry mucous membranes.
- B. The client is alert and oriented to date, time, and place.
- C. The client's ABG results are pH 7.29, PaCO2 44, HCO3 15.
- D. The client's serum potassium level is 3.3 mEq/L.
Correct Answer: B
Rationale: Alertness and orientation indicate resolving DKA, as cerebral function improves. Persistent dehydration, acidosis (pH 7.29), and hypokalemia are not signs of improvement.
Which laboratory data indicate to the nurse the client’s pancreatitis is improving?
- A. The amylase and lipase serum levels are decreased.
- B. The white blood cell (WBC) count is decreased.
- C. The conjugated and unconjugated bilirubin levels are decreased.
- D. The blood urea nitrogen (BUN) serum level is decreased.
Correct Answer: A
Rationale: Acute pancreatitis is characterized by elevated serum amylase and lipase levels due to pancreatic inflammation. A decrease in these levels indicates reduced pancreatic injury and improvement in the condition. While a decreased WBC count may suggest resolving infection, it is less specific. Bilirubin levels are relevant for biliary obstruction, not pancreatitis improvement, and BUN reflects renal function, not pancreatic status.
The client diagnosed with Cushing's disease has developed 1++ peripheral edema. The client has received intravenous fluids at 100 mL/hr via IV pump for the past 79 hours. The client received intravenous piggyback (IVPB) medication in 50 mL of fluid every six (6) hours for 15 doses. How many mL of fluid did the client receive?
Correct Answer: 8650 mL
Rationale: Continuous IV: 100 mL/hr × 79 hr = 7900 mL. IVPB: 50 mL × 15 doses = 750 mL. Total = 7900 + 750 = 8650 mL.