a client is admitted with a diagnosis of diabetic ketoacidosis dka which of the following is a priority nursing intervention

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment Form B

1. A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which of the following is a priority nursing intervention?

A. Administer a dextrose 50% IV bolus
B. Provide 8 oz of orange juice
C. Administer regular insulin IV infusion
D. Give oral metformin

Correct answer: C

Rationale: The correct answer is C: Administer regular insulin IV infusion. In diabetic ketoacidosis (DKA), the priority intervention is to rapidly decrease blood glucose levels. Administering regular insulin via IV infusion helps in lowering blood glucose effectively and quickly. Choice A, administering a dextrose 50% IV bolus, is incorrect because it would further increase blood sugar levels. Choice B, providing orange juice, is not appropriate for treating DKA as it contains sugar that will elevate blood glucose levels. Choice D, giving oral metformin, is not suitable for immediate blood glucose reduction as it acts over time and is not the first-line treatment for DKA.

2. What is the most appropriate method for assessing a patient's pain level?

A. Observe the patient's facial expressions.
B. Use a standardized pain scale, such as 0-10.
C. Ask the patient to rate their pain based on their mood.
D. Ask the patient's family members to assess the pain.

Correct answer: B

Rationale: The most appropriate method for assessing a patient's pain level is to use a standardized pain scale, such as a 0-10 scale. This method provides an objective and consistent way to measure and communicate the intensity of pain experienced by the patient. Choice A, observing facial expressions, can be subjective and may not always accurately reflect the level of pain. Choice C, asking the patient to rate their pain based on their mood, may be influenced by various factors unrelated to pain. Choice D, involving the patient's family members in assessing the pain, is not ideal as pain is a subjective experience that should be reported by the patient themselves.

3. A patient with a urinary catheter reports discomfort. What is the nurse's priority action?

A. Ensure the catheter tubing is not kinked.
B. Irrigate the catheter to relieve the discomfort.
C. Change the catheter to a smaller size.
D. Remove the catheter and replace it with a new one.

Correct answer: A

Rationale: The correct answer is to ensure the catheter tubing is not kinked. This is the priority action because a kinked tubing can obstruct urine flow, leading to discomfort and potential complications. It is essential to troubleshoot the current catheter first before considering other interventions. Irrigating the catheter (Choice B) may not address the underlying issue of kinking. Changing the catheter to a smaller size (Choice C) or removing and replacing it with a new one (Choice D) should only be considered if ensuring the tubing is unkinked does not resolve the discomfort.

4. How can dehydration be assessed in an elderly patient?

A. Checking skin turgor on the forearm
B. Assessing for dry mucous membranes
C. Checking for orthostatic hypotension
D. Measuring daily weights

Correct answer: A

Rationale: Assessing skin turgor by gently pinching the skin on the forearm is a reliable method to check for dehydration in elderly patients. When the skin is slow to return to its original position, it indicates dehydration. While assessing for dry mucous membranes is also important, checking skin turgor is a more direct method for dehydration assessment. Checking for orthostatic hypotension is more related to circulation status than dehydration. Measuring daily weights is helpful to monitor fluid balance but may not be as immediate or direct in detecting dehydration in elderly patients.

5. Which goal is most appropriate for a patient who has had a total hip replacement?

A. The nurse will assist the patient in ambulating in the hall 2 times a day.
B. The patient will walk 100 feet using a walker by the time of discharge.
C. The patient will ambulate briskly on the treadmill by the time of discharge.
D. The patient will ambulate independently by the time of discharge.

Correct answer: B

Rationale: Choice B is the most appropriate goal for a patient who has had a total hip replacement because it is specific, measurable, and achievable. Walking 100 feet using a walker is a realistic and individualized target for a patient in the recovery phase following hip surgery. Choices A, C, and D are not as suitable: Choice A does not specify a measurable distance or objective, Choice C sets a potentially unrealistic expectation for brisk ambulation on a treadmill, and Choice D lacks the specificity of the distance to be walked.