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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is c. Muscle weakness.
Choice A: Hypertension
Reason: Hypertension, or high blood pressure, is not a typical manifestation of hypokalemia. Hypokalemia primarily affects muscle function and the nervous system. While potassium imbalances can influence blood pressure, hypertension is more commonly associated with hyperkalemia (high potassium levels) rather than hypokalemia.
Choice B: Cerebral Edema
Reason: Cerebral edema, which is swelling of the brain, is not a known manifestation of hypokalemia. Hypokalemia affects muscle and nerve function, but it does not directly cause cerebral edema. This condition is more related to severe head injuries, infections, or other medical conditions.
Choice C: Muscle Weakness
Reason: Muscle weakness is a common and significant manifestation of hypokalemia. Potassium is crucial for muscle function, and low levels can lead to muscle weakness, cramps, and even paralysis in severe cases. This is because potassium helps in the transmission of nerve signals to muscles, and a deficiency disrupts this process.
Choice D: Hyperactive Bowel Sounds
Reason: Hyperactive bowel sounds are not typically associated with hypokalemia. In fact, hypokalemia can lead to decreased bowel motility, resulting in symptoms like constipation or ileus (a condition where the intestines do not move properly). This is due to the role of potassium in muscle contractions, including those in the digestive tract.
Correct Answer is B
Explanation
Choice A reason: Rigid abdomen is not a sign of diarrhea, but rather a sign of peritonitis, which is an inflammation of the abdominal lining. Peritonitis can be caused by a perforated ulcer, appendicitis, or diverticulitis.
Choice B reason: Dehydration is a sign of diarrhea, as it indicates a loss of fluid and electrolytes from the body. Dehydration can cause symptoms such as dry mouth, thirst, decreased urine output, sunken eyes, and low blood pressure.
Choice C reason: Hypothermia is not a sign of diarrhea, but rather a sign of low body temperature. Hypothermia can be caused by exposure to cold, shock, or infection.
Choice D reason: Decreased bowel sounds are not a sign of diarrhea, but rather a sign of ileus, which is a lack of intestinal activity. Ileus can be caused by surgery, medication, or obstruction.
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