Date Published: November 7, 2017
When it comes to the NCLEX Exam, it’s best to be as prepared as possible. Each week, the ATI Nursing Education Facebook page will be sharing the NCLEX Question of the Week to help you prep.
Each NCLEX-style question is reflective of a question that you could receive on the test, plus it’s paired with helpful rationales to help explain the answer.
Follow along! Follow ATI Nursing on Facebook, here.
Week of November 6 QOTW
Question: A client who is diagnosed with diabetic ketoacidosis has a serum glucose level of 580 mg/dL and a potassium level of 5.7 mEq/L.
Vital signs include: Blood pressure 88/54 mm Hg; Heart rate 136/min; Respiratory rate 40/min. Which action should the nurse implement first?
A. Reassess serum blood glucose level.
B. Begin potassium replacement therapy.
C. Administer 6 units regular insulin subcutaneously.
D. Infuse 1 liter of 0.9% sodium chloride over an hour.
CORRECT ANSWER: D
Rationale
A. The nurse should reassess blood glucose every hour to evaluate the effectiveness of therapy. When the blood glucose level reaches 300 mg/dL, IV solutions containing dextrose should be initiated to prevent hypoglycemia and cerebral edema.
B. Serum potassium levels drop once therapy is initiated. Potassium replacement is started after serum potassium levels fall below 5.0 mEq/L. The maximum infusion rate for adults should not exceed 10 mEq of potassium per hour.
C. Subcutaneous insulin has a delayed onset of action and should be administered once the client can take oral fluids and ketosis has stopped. Therefore, unless DKA is mild, a continuous IV infusion of regular insulin should be started. An initial IV bolus of regular insulin may be given at the beginning of the infusion.
D. CORRECT: The priority action is to restore volume and maintain perfusion to the brain, heart and kidneys. Hyperglycemia leads to osmotic diuresis and dehydration resulting in tachycardia and hypotension. Typically, 1 liter of 0.9% sodium chloride is administered over one hour. Lost volume as well as ongoing fluid losses should be replaced.
