Nokea
A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which intervention is most important?
- A. Administer intravenous fluids as prescribed.
- B. Monitor the client's urine output.
- C. Administer insulin as prescribed.
- D. Administer 50% dextrose IV push.
Correct Answer: C
Rationale: Administering insulin is the most important intervention in managing diabetic ketoacidosis. In DKA, there is a lack of insulin leading to hyperglycemia and ketosis. Insulin administration helps to reduce blood glucose levels and correct metabolic acidosis, which are crucial in treating DKA. Administering intravenous fluids helps with dehydration, monitoring urine output is important to assess renal function, but the priority is addressing the underlying cause of DKA by administering insulin. Administering 50% dextrose IV push is incorrect as it would further elevate blood glucose levels, which is contraindicated in DKA.
You may also like to solve these questions
The nurse is caring for a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which laboratory value should be closely monitored?
- A. Serum potassium level
- B. Hemoglobin level
- C. White blood cell count
- D. Serum calcium level
Correct Answer: A
Rationale: The correct answer is A: Serum potassium level. When a client with chronic kidney disease is receiving erythropoietin therapy, monitoring serum potassium levels is crucial due to the risk of developing hyperkalemia. Erythropoietin can stimulate red blood cell production, leading to an increase in potassium levels. Monitoring potassium helps prevent complications associated with hyperkalemia, such as cardiac arrhythmias. Choices B, C, and D are incorrect because while hemoglobin levels are relevant in assessing the effectiveness of erythropoietin therapy, monitoring potassium levels is more critical in this scenario.
A newly graduated female staff nurse requests reassignment to another client because a male client is asking her for a date and making suggestive comments. Which response is best for the nurse manager to provide?
- A. I have to call the supervisor to get someone else to transfer to this unit to care for him.
- B. I know you are a good nurse and can handle this client in a professional manner.
- C. I'll talk to the client about his behavior and insist that he stop it immediately.
- D. I'll change your assignment, but let's talk about how a nurse should respond to this kind of client.
Correct Answer: D
Rationale: The best response for the nurse manager to provide in this situation is option D, which involves changing the assignment to address the nurse's immediate concern. It also offers an opportunity to have a conversation with the nurse about how to professionally handle such situations in the future. Option A is not the best response as it does not address the underlying issue and simply shifts the problem to another staff member. Option B, while supportive, does not actively address the client's inappropriate behavior. Option C is not ideal as the nurse manager should handle discussions about inappropriate behavior with clients themselves rather than delegating it to the staff nurse.
After a sudden loss of consciousness, a female client is taken to the ED, and the initial assessment indicates that her blood glucose level is critically low. Once her glucose level is stabilized, the client reports that she was recently diagnosed with anorexia nervosa and is being treated at an outpatient clinic. Which intervention is most important to include in this client's discharge plan?
- A. Describe the signs and symptoms of hypoglycemia.
- B. Encourage a low-carbohydrate and high-protein diet.
- C. Reinforce the need to continue outpatient treatment.
- D. Suggest wearing a medical alert bracelet at all times.
Correct Answer: B
Rationale: Encouraging a low-carbohydrate and high-protein diet is crucial for a client recovering from anorexia nervosa to prevent hypoglycemic episodes. Choice A is not the most important intervention at this point since the client is already aware of hypoglycemia based on the recent event. Choice C is important but not the priority in this situation where dietary intervention is crucial. Choice D, suggesting a medical alert bracelet, is not as essential as ensuring proper nutrition to prevent further hypoglycemic episodes.
A client with chronic renal failure (CRF) is placed on a protein-restricted diet. Which nutritional goal supports this dietary change?
- A. Reduce production of urea nitrogen (BUN)
- B. Decrease the risk of hyperkalemia
- C. Promote healing of injured nephrons
- D. Promote the elimination of albumin
Correct Answer: A
Rationale: The correct answer is A: Reduce production of urea nitrogen (BUN). A protein-restricted diet is essential for clients with chronic renal failure to decrease the production of urea nitrogen, as the kidneys cannot effectively excrete it. This helps in managing the accumulation of waste products in the body. Choices B, C, and D are incorrect. Choice B is not directly related to a protein-restricted diet but focuses on managing potassium levels. Choice C is not a direct nutritional goal of a protein-restricted diet but aims at supporting kidney function. Choice D is not a target of a protein-restricted diet but relates more to managing protein loss in the urine.
A client with chronic heart failure is admitted with shortness of breath and a new onset of confusion. Which intervention should the nurse implement first?
- A. Obtain a neurological assessment.
- B. Administer oxygen therapy.
- C. Monitor the client's urine output.
- D. Obtain an electrocardiogram (ECG).
Correct Answer: A
Rationale: The correct answer is to obtain a neurological assessment. In a client with chronic heart failure presenting with confusion, the priority is to assess neurological status to rule out potential causes such as hypoxia or other complications. Administering oxygen therapy (Choice B) is important but assessing the neurological status takes precedence in this scenario. Monitoring urine output (Choice C) and obtaining an ECG (Choice D) may be necessary but are not the initial priority when a client presents with confusion alongside shortness of breath.