You are on page 1of 12

SOURCE: http://www.nursereview.

org

NCLEX/CGFNS REVIEW BULLETS 1


• The therapeutic range for serum phenytoin (Dilantin) level is 10 to 20
mcg/mL. Dilantin are given to clients with history of seizure disorder.

• The therapeutic range for the serum theophylline level is 10 to 20 mcg/mL. If


the level is below the therapeutic range, the client may be noncompliant with
the medication regimen. If the level is within the therapeutic range, the client
is most likely compliant with medication therapy. Drug is given to COPD
patients.

• The normal therapeutic range for digoxin is 0.5 to 2.0 ng/ mL. A value of 1.0
is within therapeutic range, and the nurse would administer the next dose as
scheduled.

• An International normalize ratio (INR) of 2.0 to 3.0 is appropriate for most


clients. An INR of 3.0 to 4.5 is recommended for clients with mechanical heart
valves. If the INR is below the recommended range, the warfarin sodium dose
would be increased. If the INR is above the recommended range, the warfarin
sodium dose would be decreased. Since the value identified in this question is
within the therapeutic range, the nurse would administer the next dose of
warfarin.

• An assault occurs when a person puts another person in fear of a harmful or


offensive contact. For this intentional tort to be actionable, the victim must
be aware of the threat of harmful or offensive contact. Battery is the actual
contact with one’s body. Negligence involves actions below the standards of
care. Invasion of privacy occurs when the individual’s private affairs are
unreasonably intruded. In this situation, the nurse can be charged with
battery because the nurse administers a medication that the client has
refused.

• Defamation takes place when something untrue is said (slander) or


written (libel) about a person, resulting in injury to that person’s
good name and reputation. An assault occurs when a person puts
another person in fear of a harmful or an offensive contact.
Negligence involves the actions of professionals that fall below the
standard of care for a specific professional group. Although the
physician may be aware of the biopsy results, the physician decides
when it is best to share such a diagnosis with the client.

• If the physician writes an order that requires clarification, it is the nurse’s


responsibility to contact the physician for clarification. If there is no resolution
1
regarding the order because the order remains as it was written, after the
physician has been contacted or because the physician cannot be located,
the nurse should then contact the nurse manager or supervisor for further
clarification as to what the next step should be. Under no circumstances
should the nurse proceed to carry out the order until clarification is obtained.

• Nurses need their own liability insurance for protection against malpractice
law suits. Nurses erroneously assume that they are protected by an agency’s
professional liability policies. Usually when a nurse is sued, the employer is
also sued for the nurse’s actions or inactions. Even though this is the norm,
nurses are encouraged to have their own malpractice insurance.

• A Good Samaritan Law is passed by a state legislature to encourage nurses


and other health care providers to give care to a person when an accident,
emergency, or injury occurs, without fear of being sued for the care provided.
Called “immunity from suit,” this protection usually applies only if all of the
conditions of the law are met, such as the heath care provider receives no
compensation for the care provided, and the care given is not willfully and
wantonly negligent.

• In a fire emergency, the steps to follow use the acronym RACE. The
first step is to remove the victim. The other steps are: activate the
alarm, contain the fire, then evacuate as needed. This is a universal
standard that can be applied to any type of fire emergency. The
nurse first removes the victim from the area. Pulling the nearest fire
alarm would be the next step. The nurse next contains the fire and
then extinguishes the fire.

• Generally there are only two instances in which the informed consent of an
adult client is not needed. One instance is when an emergency is present and
delaying treatment for the purpose of obtaining informed consent would
result in injury or death to the client. The second instance is when the client
waives the right to give informed consent.

• The client with hyperphosphatemia should avoid foods that are naturally high
in phosphates. These include fish, eggs, milk products, vegetables, whole
grains, and carbonated beverages. Coffee, tea, and cocoa are not high in
phosphates.

• The nurse manager needs to attend to the client assignments first. Client
care is the priority. In addition, the nursing staff needs assignments so that
they can begin client assessments and begin delivering client care. The nurse
manager should next check the crash cart (which is normally done every
shift) to ensure that needed equipment is available in the event of an
emergency. The nurse manager could also delegate this task to another
2
registered nurse while client assignments are being planned. The nurse
manager would next begin the problem-solving process related to finding a
charge nurse for the next shift. Since this activity directly affects client care,
this would be done before reading the stack of mail.

• Arriving late to work is an unacceptable behavior. Although the nurse’s


behavior has caused unrest with other staff members, the primary concern is
that this behavior affects client care. The nurse manager needs to confront
the nurse, discuss the lateness, and initiate problem-solving measures that
ensure that the behavior does not continue.

• The nurse needs to stay with the client and consult with the nurse manager
about the situation. It may be necessary for the nurse manager to contact the
supervisor to obtain an additional staff member to care for the client. Since
the client has a head injury, a major concern is the development of increased
intracranial pressure (ICP). The application of restraints may agitate the
client, causing further restlessness and thus increasing ICP. A nursing
assistant is not trained to monitor for increased ICP. It is inappropriate to ask
a family member to sit with the client.

• If a conflict arises, it is most appropriate to try to resolve the conflict directly.


In this situation, the nurse has attempted to explain the reasons for being
uncomfortable with the surgeon but was unable to resolve the conflict. The
nurse would then most appropriately use the organizational channels of
communication and discuss the issue with the nurse manager, who would
then proceed to resolve the conflict. The nurse manager may attempt to
discuss the situation with the surgeon or seek assistance from the nursing
supervisor.

• External disasters occur in the community, and many victims may be brought
to the emergency room for care. In this situation, the nurse manager would
initially contact the nursing supervisor about the need for additional staffing
and to discuss activation of the disaster plan. The nurse manager should ask,
not demand that nurses from the night shift stay until all of the victims are
treated. The nurse manager would not ask emergency medical services to
take the victims to another hospital or close the emergency room temporarily
to incoming clients. These decisions are made by administration.

• If a nurse feels that an assignment is more difficult than the assignment


delegated to other nurses on the unit, the nurse would most appropriately
discuss the assignment with the nurse manager of the neurological unit. The
nurse may or may not have a more difficult assignment than the other
nursing staff. However, this action will assist in either identifying the rationale
for the assignment or determining if the assignment is actually more difficult.
A nurse would not refuse an assignment. Specific situations may be present
3
in which a nurse should not take care of a specific client, for example, if a
pregnant nurse is assigned to care for a client with rubella or a client with an
internal radiation implant. In these situations, the nurse would also discuss
the assignment with the nurse manager. The nurse would not return to the
cardiac unit; this would be client abandonment, and this action does not
address the conflict directly.

• The signs of hypoglycemia and hyperglycemia can be difficult to


distinguish. Weakness, headache, and blurred vision can occur in
either blood glucose alteration. A blood glucose reading will assist in
confirming the diagnosis so that the appropriate action can be
taken.

• Hypoglycemia is immediately treated with 10 to 15 grams of carbohydrate.


Glucose tablets or glucose gel may be administered. Other items used to
treat hypoglycemia include 1/2 cup of fruit juice, 1/2 cup of regular (nondiet)
soft drink, 8 oz of skim milk, 6 to 10 hard candies, 4 cubes or 4 teaspoons of
sugar, 6 saltines, 3 graham crackers, or 1 tablespoon of honey or syrup.

• Most minor burns can be handled at home by the parents. For minor burns,
exposure to cool running water is the best treatment. This stops the burning
process and helps to alleviate pain. Ice is contraindicated, because it may
add more damage to already injured skin.

• When a bee sting occurs and is painful, it is best to treat the site locally
rather than systemically. Pain can be alleviated by applying an ice pack and
elevating the site.

• When a Salem sump tube is connected to suction, the air vent permits a free,
continuous flow of secretions. The air vent should never be clamped or tied
off, connected to suction, or used for irrigation. The nurse manager should
handle this problem directly with the nurse who is performing this action and
should initially review the skills checklist of the nurse who is tying the knots
to assess if this skill has ever been performed and validated.

• When cord compression is suspected, the woman is immediately


repositioned. The client’s hips can be elevated to shift the fetal presenting
part toward her diaphragm, thus relieving cord compression. A hands-and-
knees position can reduce compression on the cord that is entrapped behind
the fetus. Several position changes may be required before the fetal pattern
improves or resolves.

• If a nonreassuring fetal heart pattern occurs (tachycardia, bradycardia,


decreased variability, and late decelerations), the nurse would intervene to
increase fetal oxygenation. The oxytocin infusion is stopped immediately. The

4
infusion rate of the nonadditive IV solution is increased. The client is
positioned in a side-lying position, and oxygen via a snug facemask is
administered at 8 to 10 liters per minute. The physician is notified of the
adverse reactions, the nursing interventions that have been implemented,
and the client’s response to the interventions. The maternal blood pressure is
monitored closely.

• If physical abuse or neglect is suspected, the priority nursing action is to


assess the client, treat any physical injuries, and ensure that the client is
safe. The nurse also notifies the physician and the social worker to
investigate the situation. All states in the United States and other Western
countries have laws requiring health care professionals to report suspected
elder abuse. Calling the police is a premature action. Telling the son that he
cannot visit with his mother could initiate aggressive behavior in the son.
Although the nurse may be involved in obtaining psychiatric assistance for
the son, this is not the priority action.

• Severe leg pain, once traction has been established, indicates a problem. A
client who complains of severe pain may need realignment or may have
traction weights ordered that are too heavy. The nurse realigns the client,
and if that is ineffective, then calls the physician. The nurse never removes
traction weights unless specifically prescribed by the physician. The client
should be medicated only after an attempt has been made to determine and
treat the cause.

• With a trachea–innominate artery fistula, a malpositioned tube


causes its distal tip to push against the lateral wall of the
tracheostomy. Continued pressure from the tracheostomy tube
causes necrosis and erosion of the innominate artery. This situation
is a life-threatening complication. The tracheostomy tube is
immediately removed. Direct pressure is then applied to the
innominate artery at the stoma site. The client is then prepared for
immediate surgical repair. An IV line will need to be initiated, but
this is not the immediate action.

• The nurse should monitor the client’s heart rate and pulse oximetry during
suctioning to assess the client’s tolerance of the procedure. Oxygen
desaturation below 90% indicates hypoxemia. If hypoxia occurs during
suctioning, the nurse terminates the suctioning procedure. Using the 100%
oxygen delivery system, the client is reoxygenated until baseline parameters
are achieved. The size of the catheter should not exceed half the size of the
tracheal lumen. In adults, the standard catheter size is 12 to 14 French.
Adequate catheter size facilitates efficient removal of secretions without
causing hypoxemia.

5
• In most situations, clamping of chest tubes is contraindicated, and
agency policy and procedure must be followed with regard to
clamping a chest tube. When the client has a residual air leak or
pneumothorax, clamping the chest tube may precipitate a tension
pneumothorax because the air has no escape route. If the tube
becomes disconnected, it is best to immediately reattach it to the
drainage system or to submerge the end in a bottle of sterile water
or saline to reestablish a water seal. If sterile water or saline is not
readily available, it is preferable to leave the tube open because the
risk of tension pneumothorax outweighs the consequences of an
open tube. The physician may need to be notified, but this is not the
immediate action. The client would not be instructed to inhale.

• Surface foreign bodies are often removed simply by irrigating the eye with
sterile normal saline. The nurse would not use clamps because this action will
risk causing further injury to the eye. Applying an eye patch would not
provide relief for the problem. Visual acuity tests are not the priority at this
time, and might not be feasible because the client most likely has excessive
blinking and tearing as well at this time.

• Keratoplasty is done by removing damaged corneal tissue and replacing it


with corneal tissue from a human donor (live or cadaver). Preoperative
preparation of the recipient’s eye can include obtaining a culture and
sensitivity with conjunctival swabs, instilling antibiotic ophthalmic
medication, and cutting the eyelashes. Some ophthalmologists order a
medication such as 2% pilocarpine to constrict the pupil before surgery.

• Discharge instructions to a client after a keratoplasty includes telling the


client that sutures are usually left in place for as long as 6 months. After the
sutures are removed and complete healing has occurred, prescription glasses
or contact lenses will be prescribed.

• Enucleation is removal of the eye, leaving the eye muscles and


remaining orbital contents intact.

• Topical glucocorticoids can be absorbed in sufficient amounts to


produce systemic toxicity. Primary concerns are growth retardation
(in children), and adrenal suppression in all age groups. Systemic
toxicity is more likely under extreme conditions, such as with
prolonged therapy in which extensive surfaces are treated with high
doses of high potency agents in conjunction with occlusive
dressings.

• Isotretinoin (Accutane) is prescribed for a clietn to treat severe


cystic acne. It is usually administered two times daily for a period of
6
15 to 20 weeks. The usual adult dosage is 0.5 to 1 mg/kg/day. If
needed, a second course may be administered, but not until 2
months have elapsed after completing the first course.

• Saquinavir (Invirase) is an antiviral medication. It is administered


within 2 hours after a full meal. If the medication is taken without
food in the stomach, it may result in no antiviral activity.

• Anastrozole (Arimidex) is prescribed for a postmenopausal client with breast


cancer. The most dangerous adverse reaction to anastrozole is
thromboembolism. Common reactions include nausea, chest pain, edema,
and shortness of breath. A variety of gastrointestinal tract or nervous system
effects may also occur.

• Cytarabine (Cytosar-U) is being prescribed to a nonlymphocytic


anemia patient. The major toxic effect of cytarabine is bone marrow
depression, resulting in hematologic toxicity. Signs of hematologic
toxicity include fever, sore throat, signs of local infection, easy
bruising, or unusual bleeding from any site. If these signs occur, the
physician is notified. Anorexia, nausea, and a transient headache
can occur as side effects of the medication but do not necessarily
warrant physician notification, unless they are persistent in nature.

• Docetaxel (Taxotere) is an antineoplastic medication. Frequent side


effects include alopecia, hypersensitivity reaction, fluid retention,
nausea, vomiting, diarrhea, fever, myalgia, and nail changes. Before
receiving docetaxel, the client is premedicated with an oral
corticosteroid (dexamethasone (Decadron) 16 mg per day for 5 days,
beginning day 1 before docetaxel therapy) to reduce the severity of
fluid retention or prevent a hypersensitivity reaction.

• Paclitxel is being prescribed to a client with ovarian cancer. Side effects of


paclitaxel (Taxol) include alopecia, pain in the joints and muscles, diarrhea,
nausea, vomiting, peripheral neuropathy, hypotension, mucositis, pain and
redness at the injection site, cardiac disturbances (bradycardia), and an
abnormal electrocardiogram. Fatigue is an occasional side effect.

• Stavudine (Zerit) is prescribed for a client with advanced human


immunodeficiency virus. Peripheral neuropathy, characterized by
numbness, tingling, or pain in the hands or feet can occur frequently
with this medication and is an adverse reaction.

• Ritonavir (Norvir) oral solution is prescribed to a client with HIV virus. The
drug is preferably administered with food. It may be mixed with chocolate

7
milk or a dietary supplement to improve the taste. The client is also
instructed to consume the dose within 1 hour of mixing.

• Propofol (Diprivan) is an anesthetic agent that is used to provide continuous


sedation for a client receiving mechanical ventilation. An adverse effect of
the medication is hypotension. It can also cause respiratory depression and
bradycardia. Facial flushing can occur as an occasional side effect.

• An adverse reaction of gemcitabine hydrochloride, an antineoplastic


medication, is severe bone marrow depression, evidenced by anemia,
thrombocytopenia, and leukopenia. The medication may be discontinued or
the dosage may be modified if bone marrow depression occurs. The normal
platelet count is 150,000 to 450,000/mm3. The nurse would contact the
physician if a platelet count of 90,000/mm3 were noted. The normal range for
the total bilirubin is 8.4 to 10.2 mg/dL. The normal BUN is 7 to 25 mg/dL. The
normal range for the alkaline phosphatase is 42 to 128 units/L.

• IGIV is an immune serum that increases antibody titer and antigen-antibody


reaction, providing passive immunity against infection. Anaphylactic
reactions, although rare, can occur, and so the nurse ensures that
epinephrine is readily available when administering this medication.
Protamine sulfate is the antidote for heparin. Vitamin K is the antidote for oral
anticoagulants. Acetylcysteine is used to treat acetaminophen overdose.

• Lepirudin (Refludan) is an anticoagulant used for clients with


heparin-induced thrombocytopenia and associated thromboembolitic
disease to prevent additional thromboembolitic complications. For
the postoperative client, the initial dose is administered as soon as
possible after surgery but not more than 24 hours after surgery.

• Letrozole (Femara) is an aromatase inhibitor that is used to treat advanced


breast cancer in postmenopausal women whose disease has progressed after
antiestrogen therapy. The most frequent side effects include skeletal pain,
and back, arm, and leg pain. Less frequent side effects include nausea,
headache, fatigue, constipation, vomiting, and dyspnea.

• Amprenavir (Agenerase) is an antiretroviral agent, classified as a protease


inhibitor, used to treat HIV infection.

• Indinavir (Crisxivan) is an antiretroviral agent. This medication can


cause kidney stones; therefore, the client is instructed to increase
fluid intake to at least 1.5 liters per day. The client is also instructed
to report sharp back pain or the presence of blood in the urine. The
client is instructed to take the medication 1 hour before or 2 hours
after a large meal. If the medication needs to be taken with food,

8
the client should consume a light meal, such as dry toast, juice, or a
bowl of cereal with milk. Unexplained weight loss needs to be
reported to the physician.

• Lamivudine is an antiretroviral agent that is administered in


combination with zidovudine to delay the appearance of zidovudine
resistance. Lamivudine is well absorbed orally either with or without
food. Peripheral neuropathy can occur with its use, and the client is
instructed to notify the physician if burning, numbness, or tingling
of the hands, arms, feet, or legs occurs. Pancreatitis, evidenced by
nausea, vomiting, and abdominal pain is also an adverse reaction to
the medication, requiring physician notification.

• Levalbuterol (Xopenex) is a bronchodilator. This medication stimulates the


beta receptors in the lungs, relaxes bronchial smooth muscle, increases vital
capacity, and decreases airway resistance. Central nervous system (CNS)
stimulation can occur with the use of this medication. The client is instructed
to avoid caffeine-containing products such as coffee, tea, colas, and
chocolate, because these products can cause further CNS stimulation.

• Moxifloxacin (Avelox) is a fluoroquinolone. Increased sensitivity of


the skin to sunlight can occur, and the client is instructed to avoid
excessive sunlight and artificial ultraviolet light. The client should
wear sunscreen and protective clothing when outdoors. The client
should also drink fluids liberally and avoid the use of antacids,
because antacids will decrease absorption of the medication. The
medication can cause inflamed and ruptured tendons, so that the
client is instructed to notify the physician if inflammation or tendon
pain occurs.

• Nelfinavir (Viracept) is an antiviral medication used in the treatment of HIV


infection when antiretroviral therapy is warranted. It is available in both
tablet and powder form. The powder form is prepared by mixing the dose
with a small amount of water, milk, formula, soy milk, or dietary
supplements. The powder is not mixed with acidic foods or juices such as
apple juice or applesauce, orange juice, or grapefruit juice.

• Antacids are generally not administered with other medications because of


their interactive effects. Additionally, antacids delay the absorption of other
medications

• The client with hyperparathyroidism is likely to have elevated calcium levels.


This client should reduce the intake of dairy products such as milk, cheese,
ice cream, or yogurt. Apples, bananas, chicken, oatmeal, and pasta are
considered to be low-calcium foods.
9
• Sodium should not be limited for the client with hypercalcemia unless
contraindicated for another reason, such as cardiac disease. When sodium is
retained, then calcium is lost through the kidneys.

• The ultimate responsibility for a task lies with the person who delegated it.
Therefore, it is the nurse’s primary responsibility to follow up with each staff
member regarding the performance of the task and the outcomes related to
implementing the task. Not all staff members have the education, knowledge,
and ability to make judgments about tasks being performed. The nurse would
document that the task was completed but this would not be done until
follow-up was implemented and outcomes were identified. It is not
appropriate to assign the tasks that were not completed to the next nursing
shift.

• The client with a thoracic burn and smoke inhalation requires aggressive
pulmonary measures to prevent atelectasis and pneumonia. These include
turning and repositioning, using humidified oxygen, providing incentive
spirometry, and suctioning on an as-needed basis. The client should not be
left lying in a single position and should not have the head of bed flat. These
could promote the development of complications by limiting chest expansion.

• Wound dehiscence is the disruption of the surgical incision or wound. When


dehiscence occurs, the nurse immediately places the client in low-Fowler’s
position and instructs the client to lie quietly. These actions will minimize
protrusion of the underlying body tissues. The nurse then covers the
abdominal wound with a sterile dressing moistened with sterile saline. The
physician is then notified and the nurse documents the occurrence and the
nursing actions implemented.

• Adult diabetes mellitus can be diagnosed either by symptoms (polydipsia,


polyuria, polyphagia), or by laboratory values. Diabetes mellitus is diagnosed
by an abnormal glucose tolerance test, or when random plasma glucose
levels are greater than 200 mg/dL, or fasting plasma glucose levels are
greater than 140 mg/dL on two separate occasions.

• Hemorrhage is a potential complication following tonsillectomy and


adenoidectomy. If the client vomits large amounts of altered blood or bright
red blood, or if the pulse rate or temperature rises and the client is restless,
the nurse must notify the surgeon immediately. The nurse should obtain a
light, mirror, gauze, curved hemostats, and a waste basin for examination of
the surgical site. The nurse would also gather additional assessment data,
but the immediate nursing action would be to contact the surgeon.

• The client with hypertension is at risk for cardiovascular complications, such


as angina pectoris, myocardial infarction, and heart failure. Thyroid
10
preparations increase metabolic rate, oxygen demands, and demands on the
heart. The client should know to report the onset of chest pain immediately.
Lethargy, constipation, and weight gain are symptoms of hypothyroidism,
which should improve with medication therapy such as levothyroxine sodium.

• Pulmonary embolism is a life-threatening emergency. Nasal oxygen is


administered immediately to relieve hypoxemia, respiratory distress, and
central cyanosis. IV infusion lines are needed to administer medications or
fluids. A perfusion scan, among other tests, may be performed. The ECG is
monitored for the presence of dysrhythmias. Additionally, a urinary catheter
may be inserted and arterial blood gases may be drawn. However, the
immediate nursing action is to administer oxygen.

• Fludrocortisone acetate (Florinef) is a long-acting oral medication with


mineralocorticoid and moderate glucocorticoid activity. It is prescribed for the
long-term management of Addison’s disease. Mineralocorticoids cause renal
resorption of sodium and chloride ions, and the excretion of potassium and
hydrogen ions. These actions help restore electrolyte balance in the body.

• The client with diabetic neuropathy of the lower extremities has diminished
ability to feel sensations in the legs and feet. This client is at risk for tissue
injury and for falls as a result of this nervous system impairment.

• A traumatic open pneumothorax is an emergency. Stopping the flow of air


through the opening in the chest wall is a life saving measure. In such an
emergency, anything may be used that is large enough to fill the chest
wound including a towel, a handkerchief, or the heel of the hand. If
conscious, the victim is instructed to inhale and strain against a closed
glottis. This action assists in reexpanding the lung and ejecting the air from
the thorax. In the hospitalized client who experiences an open
pneumothorax, the opening is plugged by sealing it with gauze impregnated
with petrolatum.

• The client with severe osteoporosis as a result of hyperparathyroidism is at


great risk for injury as a result of pathological fractures from bone
demineralization. The client may or may not have a risk for impaired urinary
elimination, depending on other elements in the client history, and whether
or not the client is at risk for stone formation from high serum calcium levels.
The client may also have a risk for constipation from the disease process, but
this would be a lesser priority than client safety. A risk for ineffective health
maintenance may be a concern but is not the priority.

• Clients with myxedema or hypothyroidism have decreased metabolic


demands from reduced metabolic rate. For this reason they often experience

11
weight gain. The diet should be low in calories overall and yet be
representative of all food groups.

• Hypoparathyroidism results in hypocalcemia. A therapeutic diet for this


disorder then is one that is high in calcium but low in phosphorus, because
these two electrolytes have inverse proportions in the body.

• Constant bubbling in the water seal chamber of a closed chest tube drainage
system may indicate the presence of an air leak. The nurse would assess the
chest tube system for the presence of an external air leak if constant
bubbling were noted in this chamber. If no external air leak is present, the
physician is notified immediately because an air leak may be present in the
pleural space. Leaking and trapping of air in the pleural space can result in a
tension pneumothorax.

• The client taking NPH insulin obtains peak medication effects 6 to 12 hours
after administration. At the time that the medication peaks, the client is at
risk of hypoglycemia if food intake is insufficient. The nurse would teach the
client to watch for signs and symptoms of hypoglycemia, including anxiety,
confusion, difficulty concentrating, blurred vision, cold sweating, headache,
increased pulse, shakiness, and hunger.

• Before doing a fingerstick for blood glucose measurement, the client should
first wash the hands. Warm water should be used to stimulate the circulation
to the area. The finger is punctured near the side, not the center, since there
are fewer nerve endings along the side of the finger. The puncture is only
deep enough to obtain an adequately sized drop of blood; excessively deep
punctures can lead to pain and bruising. The arm should be allowed to hang
dependently, and the finger can be milked to promote obtaining a good size
blood drop.

• Diabetic clients should take in approximately 15 grams of carbohydrate every


1 to 2 hours when unable to tolerate food due to illness.

• The client with DKA initially becomes hyperkalemic as potassium leaves the
cells in response to a lowered pH. Once fluid replacement and insulin therapy
are started, the potassium level drops quickly. This occurs because
potassium is carried into the cells along with glucose and insulin, and also
because potassium is excreted in the urine once rehydration has occurred.
Thus, the nurse must plan to monitor the results of serum potassium levels
carefully, and report hypokalemia.

12