A nurse is assisting in the care of a client who has diabetic ketoacidosis and hypoxia. Which of the following actions should the nurse take first?
Obtain a prescription to administer insulin.
Obtain a prescription for supplemental oxygen.
Obtain a prescription to check the client's glucose level.
Obtain a prescription to administer intravenous fluids.
The Correct Answer is B
Choice A reason: Obtaining a prescription to administer insulin is an important action for the nurse to take, as insulin helps to lower the blood glucose level and reverse the metabolic acidosis caused by diabetic ketoacidosis. However, it is not the first action the nurse should take, as the client's hypoxia is a more urgent problem that requires immediate intervention.
Choice B reason: Obtaining a prescription for supplemental oxygen is the first action the nurse should take, as hypoxia is a life-threatening condition that can lead to tissue damage, organ failure, and death. The nurse should provide oxygen therapy to improve the client's oxygen saturation and prevent further complications.
Choice C reason: Obtaining a prescription to check the client's glucose level is a necessary action for the nurse to take, as glucose monitoring helps to evaluate the client's response to insulin therapy and guide further interventions. However, it is not the first action the nurse should take, as the client's hypoxia is a more urgent problem that requires immediate intervention.
Choice D reason: Obtaining a prescription to administer intravenous fluids is a beneficial action for the nurse to take, as fluid replacement helps to correct the dehydration, electrolyte imbalance, and hypotension caused by diabetic ketoacidosis. However, it is not the first action the nurse should take, as the client's hypoxia is a more urgent problem that requires immediate intervention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Collecting urine from the catheter's port is not a correct action for the nurse to take, as it can introduce contamination and infection into the urinary tract. The nurse should insert a new, sterile catheter into the bladder and collect the urine directly from the catheter.
Choice B reason: Using a sterile specimen container is a correct action for the nurse to take, as it ensures that the urine sample is not contaminated by any bacteria or other substances. The nurse should label the container with the client's name, date, and time of collection and send it to the laboratory as soon as possible.
Choice C reason: Using sterile water to inflate the balloon is not a relevant action for the nurse to take, as it applies to an indwelling catheter, not a straight catheter. A straight catheter does not have a balloon and is removed after the urine is drained.
Choice D reason: Instructing the client to clean from front to back with an antiseptic solution is a good action for the nurse to take, as it helps to prevent the introduction of bacteria from the anal area into the urethra. However, it is not the best answer, as it is a general hygiene measure, not a specific action for obtaining a urine specimen.
Correct Answer is B
Explanation
Choice A reason: Tachycardia is not an adverse effect of oxygen therapy. Tachycardia is a condition where the heart rate is faster than normal, usually above 100 beats per minute. Tachycardia can be caused by various factors, such as fever, infection, pain, or anxiety. Tachycardia can also be a sign of hypoxemia, which is a low level of oxygen in the blood, and may indicate the need for oxygen therapy.
Choice B reason: Cracks in oral mucous membranes are an adverse effect of oxygen therapy. Cracks in oral mucous membranes are a sign of dryness and irritation caused by the oxygen flow. Oxygen therapy can reduce the natural moisture and lubrication of the mouth and nose, leading to discomfort and increased risk of infection. To prevent or treat this problem, the nurse should provide the client with humidified oxygen, oral care, and hydration.
Choice C reason: Excessive pulmonary secretions are not an adverse effect of oxygen therapy. Excessive pulmonary secretions are a sign of inflammation and infection in the lungs, which can impair gas exchange and cause coughing, wheezing, and dyspnea. Excessive pulmonary secretions can be a symptom of pneumonia, which is a common cause of respiratory failure and may require oxygen therapy.
Choice D reason: Poor skin turgor is not an adverse effect of oxygen therapy. Poor skin turgor is a sign of dehydration, which is a loss of fluid from the body. Dehydration can be caused by various factors, such as vomiting, diarrhea, fever, or inadequate intake. Dehydration can affect the blood volume and pressure, and may worsen the oxygen delivery to the tissues. To prevent or treat this problem, the nurse should monitor the client's fluid balance and provide adequate hydration.
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