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 action for handling hazardous drugs?

A. Wear gloves and wash hands after handling.
B. Store the drugs according to manufacturer instructions.
C. Discard unused drugs in regular trash.
D. Wear personal protective equipment (PPE) when handling hazardous drugs.

Correct answer: D

Rationale: The most appropriate action when handling hazardous drugs is to wear personal protective equipment (PPE) to protect oneself from exposure to the harmful substances. Gloves and handwashing are important but may not provide sufficient protection from hazardous drugs. Storing drugs correctly and disposing of unused drugs properly are also essential, but the primary focus should be on using PPE to prevent exposure.

3. What are the nursing interventions for a patient with pneumonia?

A. Providing fluids and rest
B. Monitoring lung sounds and respiratory rate
C. Encouraging coughing and deep breathing exercises
D. Administering antibiotics and providing oxygen therapy

Correct answer: B

Rationale: The correct nursing interventions for a patient with pneumonia include monitoring lung sounds and respiratory rate to assess the effectiveness of treatment and the patient's respiratory status. Providing fluids and rest (Choice A) can be supportive measures but are not specific nursing interventions for pneumonia. Encouraging coughing and deep breathing exercises (Choice C) can be helpful for airway clearance but may not be appropriate for all patients with pneumonia. Administering antibiotics and providing oxygen therapy (Choice D) are medical interventions rather than nursing interventions.

4. A nurse manager on an acute care unit is preparing a staff presentation about promoting cost-effective care. Which of the following strategies should the nurse plan to include in the presentation?

A. Change IV solution bags every 36 hr.
B. Avoid the delegation of hygiene care to assistive personnel (AP)
C. Wear sterile gloves when removing urinary retention catheters.
D. Educate staff about the correct use of personal protective equipment (PPE) for isolation precautions

Correct answer: D

Rationale: Teaching staff proper use of PPE helps reduce the spread of infections and promotes cost-effective care.

5. What are the clinical manifestations of left-sided heart failure, and how do they differ from right-sided heart failure?

A. Jugular venous distention and hepatojugular reflex
B. Hepatomegaly, ascites, and peripheral edema
C. Dyspnea, cough, and orthopnea
D. Pulmonary congestion and fatigue

Correct answer: A

Rationale: The correct answer is A. Clinical manifestations of left-sided heart failure include pulmonary symptoms such as dyspnea, cough, and orthopnea. However, left-sided heart failure can also manifest as jugular venous distention and hepatojugular reflex due to the backflow of blood into the pulmonary circulation. Right-sided heart failure is characterized by systemic symptoms like hepatomegaly, ascites, and peripheral edema. Choice B is incorrect as it presents manifestations of right-sided heart failure. Choice C includes symptoms of left-sided heart failure. Choice D describes pulmonary congestion, which is more specific to left-sided heart failure, but it does not encompass the full range of clinical manifestations for left-sided heart failure.