A client with type 1 diabetes mellitus (DM) is admitted to the hospital for an emergency cholecystectomy. The client explains to the nurse about experiencing difficulty at home in keeping blood glucose levels under 200 mg/dl (11.1 mmol/L). To prevent the client from developing diabetic ketoacidosis (DKA), which intervention is most important for the nurse to include in the plan of care?
a) Obtain a fingerstick glucose every 6 hours.
b) Ensure IV fluids are infusing continuously.
c) Test urine for the presence of ketones.
d) Teach the client how to manage sick days.

The correct answer is: c) Test urine for the presence of ketones.

Choice A reason: Obtaining a fingerstick glucose every 6 hours is important for monitoring blood glucose levels and ensuring they are within the target range. However, it is not the most critical intervention for preventing diabetic ketoacidosis. Testing for ketones provides more specific information on the development of DK

Choice A reason: Applying soft restraints to all extremities is not appropriate during a seizure as it can increase the risk of injury. The priority is to ensure the client's safety by preventing injury without restraining them.

Choice B reason: Removing objects that could cause injury is crucial. During a seizure, the client may move unpredictably, and any nearby objects could pose a risk of harm. Clearing the area ensures the client has a safe space to have the seizure without additional hazards.

Choice C reason: Placing pillows around the client's head can provide some protection, but it is not as immediately effective or necessary as removing potentially harmful objects from the surrounding area. Ensuring a clear and safe environment is the primary concern.

Choice D reason: Administering oxygen per nasal cannula is not the first priority during a seizure. While maintaining oxygenation is important, the immediate focus should be on ensuring the client's physical safety by removing dangerous objects. Once the seizure subsides, appropriate respiratory support can be provided if needed.

Choice A reason: Obtaining a fingerstick glucose every 6 hours is important for monitoring blood glucose levels and ensuring they are within the target range. However, it is not the most critical intervention for preventing diabetic ketoacidosis. Testing for ketones provides more specific information on the development of DKA.

Choice B reason: Ensuring IV fluids are infusing continuously is crucial for maintaining hydration and preventing electrolyte imbalances, particularly in a client who may be at risk for DKA. However, this intervention is supportive and not as directly related to detecting the onset of DKA as testing for ketones.

Choice C reason: Testing urine for the presence of ketones is the most important intervention. The presence of ketones indicates that the body is breaking down fat for energy instead of using glucose, which is a hallmark of diabetic ketoacidosis. Early detection of ketones allows for prompt intervention to prevent the progression of DKA.

Choice D reason: Teaching the client how to manage sick days is essential for long-term diabetes management and preventing complications during illness. However, for the immediate prevention of DKA in the hospital setting, testing for ketones is more urgent and directly related to detecting and managing the condition.