Nokea
The nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following would indicate the client is achieving the treatment goals?
- A. Mean arterial pressure (MAP) 71 mmHg
- B. Potassium 3.3 mEq/L (mmol) [3.5-5 mEq/L]
- C. Blood glucose 255 mg/dL (14.15 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]
- D. Serum pH 7.33 [7.35 and 7.45]
Correct Answer: D
Rationale: In DKA, treatment aims to correct acidosis, hyperglycemia, and electrolyte imbalances. A serum pH of 7.33 is closer to the normal range (7.35-7.45), indicating improvement in acidosis. MAP of 71 mmHg is low, potassium is below normal, and glucose remains elevated, suggesting ongoing issues.
You may also like to solve these questions
The nurse is caring for a client with Cushing's disease. Which of the following complications are associated with this condition?
- A. cataracts
- B. diabetes mellitus
- C. orthostatic hypotension
- D. osteoporosis
- E. venous thromboembolism
Correct Answer: A, B, D, E
Rationale: Cushing's excess cortisol causes cataracts, diabetes from hyperglycemia, osteoporosis from bone loss, and thromboembolism from hypercoagulability. Orthostatic hypotension is not typical.
The nurse is caring for a client experiencing an adrenal crisis (Addisonian crisis). The nurse should be prepared to administer which intravenous fluid?
- A. Lactated Ringers (LR)
- B. 0.9% saline
- C. Dextrose 5% in water (D5W)
- D. Dextrose 5% in water and Lactated Ringers (D5LR)
Correct Answer: B
Rationale: 0.9% saline is used in adrenal crisis to correct hypotension and hyponatremia caused by cortisol and aldosterone deficiency. D5W or D5LR may be used later, but saline is the priority for fluid resuscitation.
The nurse observes the newly hired registered nurse prepare to administer neutral protamine hagedorn (NPH) insulin to a client. Which action by the newly hired nurse requires follow-up?
- A. asks the client which site the insulin was last injected.
- B. checks the client's blood glucose levels prior to administering the insulin injection.
- C. shakes the insulin vial before withdrawing insulin.
- D. reminds the client to report symptoms of clammy skin and disorientation.
Correct Answer: C
Rationale: NPH insulin should be gently rolled, not shaken, to mix the suspension without creating bubbles, which can affect dosing accuracy. Asking about injection sites, checking glucose, and reminding about hypoglycemia symptoms are correct actions.
A post-adrenalectomy client is admitted to the intensive care unit and is on intravenous hydrocortisone. Which nursing intervention should be included in the client's plan of care?
- A. Monitor blood glucose levels frequently
- B. Keep the client supine for 24 hours
- C. Discontinue hydrocortisone once vital signs become stable
- D. Educate the client on how to properly clean the wound at home
Correct Answer: A
Rationale: Adrenalectomy removes cortisol production; hydrocortisone replacement can raise glucose. Frequent monitoring prevents hyperglycemia. Keeping supine is unnecessary, discontinuation risks adrenal crisis, and wound care education is premature in ICU.
The nurse is counseling a client who has prediabetes. The nurse understands that the client is meeting the treatment goal, as evidenced by
- A. total cholesterol of 215 mg/dL (5.55 mmol/L) [ < 200 mg/dL, < 5.2 mmol/L]
- B. hemoglobin A1C of 5.4% [ < 6.4%]
- C. fasting blood glucose 128 mg/dL (7.10 mmol/L) [70-110 mg/dL, 4.0-6.0 mmol/L]
- D. random blood glucose of 210 mg/dL (11.66 mmol/L) [70-110 mg/dL, 4.0-6.0 mmol/L]
Correct Answer: B
Rationale: Prediabetes goals include HbA1C <5.7%; 5.4% indicates good control. Elevated cholesterol, fasting, and random glucose suggest ongoing issues.