a 54 year old patient is admitted with diabetic ketoacidosis which admission order should the nurse implement first

ATI RN

ATI Leadership Proctored Exam 2023

1. A 54-year-old patient is admitted with diabetic ketoacidosis. Which admission order should the nurse implement first?

A. Infuse 1 liter of normal saline per hour.
B. Give sodium bicarbonate 50 mEq IV push.
C. Administer regular insulin 10 U by IV push.
D. Start a regular insulin infusion at 0.1 units/kg/hr.

Correct answer: A

Rationale: In a patient admitted with diabetic ketoacidosis, the initial priority is to address dehydration and electrolyte imbalances. Infusing 1 liter of normal saline per hour helps correct hypovolemia and restore electrolyte balance, making it the first essential step in managing diabetic ketoacidosis. Sodium bicarbonate is not routinely recommended in treating diabetic ketoacidosis and should not be given routinely as it may worsen the acidosis. Administering regular insulin and starting an insulin infusion are important but should come after fluid resuscitation to stabilize the patient's condition.

2. A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching they received about pain management?

A. ''I think I should take my pain medication more often, since it is not controlling my pain.''
B. ''Breathing faster will help me keep my mind off of the pain.''
C. ''It might help me to listen to music while I'm lying in bed.''
D. ''I don't want to walk today because I have some pain.''

Correct answer: D

Rationale: The correct answer is D because the client is demonstrating an understanding of the preoperative teaching by acknowledging the pain and relating it to the need to rest. Walking may exacerbate the pain, and the client's decision not to walk shows an awareness of their body's signals. Choices A, B, and C are incorrect as they do not reflect a good understanding of pain management. Choice A suggests self-medicating without consulting healthcare providers, choice B focuses on distraction rather than addressing the pain, and choice C offers a coping mechanism but does not address the pain directly.

3. Under which category does a violation of the nurse practice act fall?

A. Juvenile
B. Felony
C. Misdemeanor
D. Tort

Correct answer: B

Rationale: A violation of the nurse practice act falls under the category of a felony. Felony offenses are the most serious and can include acts like homicide and violations of professional practice regulations. Choices A, C, and D are incorrect because violations of the nurse practice act are considered more severe than misdemeanors, torts, or related to juvenile cases.

4. A nurse is evaluating teaching for a client who has heart failure. Which of the following statements by the client indicates an understanding of the teaching?

A. I am limiting my sodium intake to 2 grams daily.
B. I have been weighing myself every other morning.
C. I am trying to decrease my intake of foods with potassium.
D. I am eating fewer potato chips and more fruit for snacks.

Correct answer: A

Rationale: The correct answer is A. Limiting sodium intake is crucial for clients with heart failure to manage their condition effectively. Excessive sodium can lead to fluid retention and worsen heart failure symptoms. Weighing oneself is important for monitoring fluid retention but does not directly show an understanding of dietary restrictions. Decreasing potassium intake is not typically recommended for heart failure clients unless specifically advised by a healthcare provider. While choosing healthier snacks is beneficial, the focus on sodium intake is more critical for heart failure management.