A child has been diagnosed with diabetic ketoacidosis (DKA) and is in the pediatric intensive care unit. Which nursing diagnosis does the nurse direct interventions toward as the priority?
A.
Fluid volume deficit
B.
Ineffective breathing patterns
C.
Knowledge deficit
D.
Risk for infection
ANS: A
Because the child with DKA can be severely dehydrated, priority interventions are directed toward the goal of rehydration. Breathing patterns for the child in DKA may consist of Kussmaul respirations, which are actually the body's way of trying to compensate for the acidosis. As the glucose decreases, this will self-correct. Knowledge deficit can be addressed when the child's condition is stable. Risk for infection is always a potential
diagnosis, and the nurse ensures proper technique to prevent this from occurring. But because the dehydration is so severe, this takes priority.
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