Page 958 - Saunders Comprehensive Review For NCLEX-RN

adjusted or changed. From the remaining options, note the words positive for ketones
in the question. Recalling that liquids are essential to aid in clearing the ketones will
direct you to the correct option.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Pediatrics: Metabolic/Endocrine
Health Problem: Pediatric-Specific: Diabetes mellitus
Priority Concepts: Clinical Judgment; Glucose Regulation
Reference: McKinney et al. (2018), p. 1268.

325. Answer: 4

Rationale: In hypotonic dehydration, electrolyte loss exceeds water loss. The
priority assessment before administering potassium chloride intravenously would
be to assess the status of the urine output. Potassium chloride should never be
administered in the presence of oliguria or anuria. If the urine output is less than 1 to
2 mL/kg/hr, potassium chloride should not be administered. Although options 1, 2,
and 3 are appropriate assessments for a child with dehydration, these assessments
are not related specifically to the IV administration of potassium chloride.
Test-Taking Strategy: Note the strategic word, priority. Focus on the IV
prescription. Recalling that the kidneys play a key role in the excretion and
reabsorption of potassium will direct you to the correct option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Pediatrics: Metabolic/Endocrine
Health Problem: Pediatric-Specific: Dehydration
Priority Concepts: Clinical Judgment; Fluids and Electrolytes
Reference: McKinney et al. (2018), p. 895.

326. Answer: 4

Rationale: Diabetic ketoacidosis is a complication of diabetes mellitus that
develops when a severe insulin deficiency occurs. Hyperglycemia occurs with
diabetic ketoacidosis. Signs of hyperglycemia include fruity breath odor and a
decreasing level of consciousness. Hunger can be a sign of hypoglycemia or
hyperglycemia, but hypertension is not a sign of diabetic ketoacidosis. Hypotension
occurs because of a decrease in blood volume related to the dehydrated state that
occurs during diabetic ketoacidosis. Cold clammy skin, irritability, sweating, and
tremors all are signs of hypoglycemia.
Test-Taking Strategy: Focus on the subject, the signs of diabetic ketoacidosis, and
recall that in this condition the blood glucose level is elevated. Eliminate options 1, 2,
and 3 because these signs do not occur with hyperglycemia. Recall that fruity breath
odor and a change in the level of consciousness can occur during diabetic
ketoacidosis.
Level of Cognitive Ability: Analyzing

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