The client is admitted to the ICU diagnosed with DKA. Which...

The client is admitted to the ICU diagnosed with DKA. Which interventions should the nurse implement? Select all that apply.

A. Maintain adequate ventilation.
B. Assess fluid volume status.
C. Administer intravenous potassium.
D. Check for urinary ketones.
E. Monitor intake and output.

Correct Answer: A,B,D,E

Rationale: Ventilation, fluid status, ketone checks, and I&O monitoring manage DKA’s acidosis, dehydration, and ketosis. Potassium is given only if low, not routinely.

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The nurse identifies the client problem 'risk for imbalanced body temperature' for the client diagnosed with hypothyroidism. Which intervention should be included in the plan of care?

A. Discourage the use of an electric blanket.
B. Assess the client's temperature every two (2) hours.
C. Keep the room temperature cool.
D. Space activities to promote rest.

Correct Answer: A

Rationale: Hypothyroidism causes cold intolerance; discouraging electric blankets prevents burns due to reduced sensation. Frequent temperature checks, cool rooms, and rest are less relevant.

The nurse administers a usual morning dose of 4 units of regular insulin and 8 units of NPH insulin at 7:30 am to the client with a blood glucose level of 110 mg/dL. Which statements regarding the client's insulin are correct?

A. The onset of the regular insulin will be at 7:45 am and the peak at 1:00 pm.
B. The onset of the regular insulin will be at 8:00 am and the peak at 10:00 am.
C. The onset of the NPH insulin will be at 8:00 am and the peak at 10:00 am.
D. The onset of the NPH insulin will be at 12:30 pm and the peak at 11:30 pm.

Correct Answer: B

Rationale: The onset of regular insulin (short acting) is one-half to 1 hour, and the peak is 2 to 3 hours. The onset of NPH insulin (intermediate acting) is 2 to 4 hours, and the peak is 4 to 12 hours.

The client with an acute exacerbation of chronic pancreatitis has a nasogastric (N/G) tube. Which interventions should the nurse implement? Select all that apply.

A. Monitor the client's bowel sounds.
B. Monitor the client's food intake.
C. Assess the client's intravenous site.
D. Provide oral and nasal care.
E. Monitor the client's blood glucose.

Correct Answer: A,C,D,E

Rationale: Monitoring bowel sounds, IV site, oral/nasal care, and glucose manage NG tube complications and pancreatitis-related risks (e.g., hyperglycemia). Food intake is irrelevant with NPO status.

The nurse is reviewing the serum laboratory report for the hospitalized client who has adrenocortical insufficiency. The nurse should immediately notify the HCP about which value?

A. WBC 11,000/mm3
B. Glucose 138 mg/dL
C. Sodium 148 mEq/L
D. Potassium 6.2 mEq/L

Correct Answer: D

Rationale: The serum potassium of 6.2 mEq/L indicates hyperkalemia, which can cause dysrhythmias and requires immediate notification.

The home health nurse is completing the first home visit for the elderly Hispanic client newly diagnosed with type 2 DM. The client has been instructed on self-administering NPH and regular insulin in the morning and at suppertime. What information should the nurse reinforce when teaching the client? Select all that apply.

A. Inspect the feet and between the toes daily.
B. Use magnifying devices to read small print.
C. Perform a hemoglobin A1c test once a week.
D. Eat a 15-gram carbohydrate snack at bedtime.
E. Inject 1 unit of NPH insulin after eating a snack

Correct Answer: A,B,D

Rationale: Daily foot inspection prevents complications, magnifying devices prevent dosing errors, and a bedtime snack covers insulin peaks to prevent hypoglycemia.