A client one (1) day postoperative for coronary artery bypass graft (CABG) reports chest pain.
Which intervention should the nurse implement first?

Choice D rationale

Ensuring a clear airway is the priority intervention in cases of diabetic ketoacidosis with hypoxia. Hypoxia refers to a deficiency in the amount of oxygen reaching tissues. Without a clear airway, oxygen cannot be effectively delivered to the lungs, and subsequently to the bloodstream and tissues. Addressing the client's airway ensures that oxygenation can be improved promptly, which is critical in preventing further complications and maintaining vital functions.

Choice A rationale

While it is important to monitor blood glucose levels in diabetic ketoacidosis, it is not the immediate priority when the client is also experiencing hypoxia. Blood glucose testing does not directly address the oxygen deficiency, which needs urgent attention to prevent severe outcomes.

Choice B rationale

Administering a bronchodilator can help improve breathing in some cases; however, it is not the first step in managing hypoxia and diabetic ketoacidosis. The primary focus should be on ensuring a patent airway to facilitate adequate oxygen delivery.

Choice C rationale

Monitoring vital signs is essential in managing any acute condition; however, in this scenario, ensuring a clear airway to address hypoxia is the most critical intervention. Monitoring alone does not resolve the immediate issue of oxygen deprivation.

Choice A rationale

Administering a laxative is not necessary for a CT scan of the abdomen with contrast. Laxatives are typically used for bowel preparation for procedures like colonoscopies.

Choice B rationale

Biguanide medications such as metformin should be held before and after the administration of contrast medium to prevent lactic acidosis, particularly in clients with liver disease.

Choice C rationale

Fasting for 24 hours is not required before a CT scan with contrast medium. Typically, clients are asked to fast for a few hours prior to the procedure.

Choice D rationale

Ensuring the client is adequately hydrated helps to protect kidney function and reduce the risk of contrast-induced nephropathy. Hydration is especially important for clients with a history of liver disease.