A patient with type 1 diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). What is the priority nursing action?

Correct Answer: A

Rationale: The correct answer is A: Administer regular insulin intravenously. In DKA, the priority is to lower blood glucose levels and correct acidosis. Regular insulin intravenously is the fastest way to reduce blood glucose levels. Oral hypoglycemic agents (B) are not effective in DKA. Sodium bicarbonate (C) is not routinely recommended in DKA as it may worsen acidosis. Providing a high-calorie diet (D) is not appropriate as the focus should be on treating the underlying condition first.

Correct Answer: C

Rationale: The correct answer is C: Before meals. Omeprazole is a proton pump inhibitor that works by reducing stomach acid production. Taking it before meals allows the medication to be most effective in inhibiting the proton pumps before they are stimulated by food intake. This timing optimizes the drug's ability to reduce acid secretion during the digestion process. Choice A (With meals) is incorrect because taking omeprazole with meals may reduce its effectiveness as it will not have enough time to inhibit acid production before food intake. Choice B (At bedtime) is also incorrect as omeprazole works best when taken before meals to prevent acid production. Choice D (After meals) is incorrect because waiting until after meals to take omeprazole means that acid production has already been stimulated by the food consumed, reducing the drug's effectiveness in inhibiting acid secretion.

Correct Answer: B

Rationale: The correct answer is B: Nausea and vomiting. This finding requires immediate intervention because digoxin toxicity can present with gastrointestinal symptoms like nausea and vomiting. This can indicate an overdose of digoxin, which can be life-threatening. Prompt action is necessary to prevent further complications. A: Heart rate of 58 beats per minute is within the therapeutic range for digoxin and does not require immediate intervention. C: Blood pressure of 130/80 mm Hg is also within normal limits and does not indicate an urgent issue. D: Shortness of breath can be a symptom of heart failure but is not a direct indication of digoxin toxicity requiring immediate intervention.

Correct Answer: D

Rationale: The correct answer is D: Encourage fluid intake up to 4000 mL every day. High calcium levels can lead to dehydration, so encouraging fluid intake helps prevent this complication. Increased fluid intake also promotes calcium excretion through urine. Bed rest (A) is not directly related to managing high calcium levels. Auscultating lung sounds (B) every 4 hours is more relevant for respiratory issues. Monitoring for Trousseau's and Chvostek's signs (C) is associated with low calcium levels, not high levels.

Correct Answer: A

Rationale: The correct answer is A: Serum amylase. In acute pancreatitis, damaged pancreatic cells release amylase into the bloodstream, causing elevated serum amylase levels. Monitoring serum amylase helps in diagnosing and assessing the severity of pancreatitis. Incorrect choices: B: Serum sodium - Serum sodium levels are typically not directly affected by pancreatitis. C: Serum calcium - While hypocalcemia can occur in severe pancreatitis, monitoring serum calcium is not as specific for pancreatitis diagnosis or severity assessment as serum amylase. D: Serum potassium - Potassium levels may be affected in pancreatitis due to vomiting or dehydration, but monitoring serum potassium is not as specific to pancreatitis as serum amylase.

Correct Answer: B

Rationale: The correct answer is B: To relieve abdominal pressure. Paracentesis is performed to drain excess fluid from the abdominal cavity, which helps alleviate symptoms like abdominal distension and discomfort in clients with ascites. It does not serve the purpose of diagnosing liver disease (A), assessing kidney function (C), or reducing blood pressure (D). The primary goal of paracentesis in this context is to provide symptomatic relief by removing the accumulated fluid, thereby reducing pressure on surrounding organs and improving the client's comfort and overall well-being.

Correct Answer: C

Rationale: Rationale: C is correct because thiazide diuretics can cause fluid retention, leading to weight gain, which may indicate worsening heart failure or hypertension. Daily weight monitoring helps detect fluid retention early, enabling timely intervention. Summary: A: Incorrect. Thiazide diuretics can cause potassium loss, so avoiding potassium-rich foods is not necessary. B: Incorrect. Taking the medication in the morning is preferred to prevent nocturia and sleep disturbances. D: Incorrect. Fluid intake should not be limited unless advised by a healthcare provider to prevent dehydration.

Correct Answer: C

Rationale: The correct answer is C: Increased ammonia levels. In hepatic encephalopathy, the liver is unable to metabolize ammonia into urea, leading to increased ammonia levels in the blood. A low-protein diet helps reduce ammonia production in the gut, thereby decreasing ammonia levels in the blood and improving symptoms. Hyperglycemia (A) and hypoglycemia (B) are not directly related to the rationale for a low-protein diet in hepatic encephalopathy. Electrolyte imbalance (D) is not specifically addressed by a low-protein diet in this context.

Correct Answer: B

Rationale: The correct answer is B: Muscle weakness. Myasthenia gravis is characterized by muscle weakness due to an autoimmune attack on acetylcholine receptors at the neuromuscular junction. This leads to impaired muscle contraction and weakness, especially in the face, neck, and extremities. Joint pain (A) is not a typical symptom of myasthenia gravis. Loss of sensation (C) is more indicative of a sensory nerve disorder rather than a motor disorder like myasthenia gravis. Severe headache (D) is not a common symptom of myasthenia gravis; it is more likely to be associated with other conditions such as migraines or intracranial pathology.