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 D
Explanation
Choice A reason: Reflex incontinence is not a sign of the need to catheterize the client, as it is a type of involuntary urine loss that occurs when the bladder is overfilled and the sphincter relaxes. Reflex incontinence can be managed by following a regular catheterization schedule, not by waiting for symptoms.
Choice B reason: Urge incontinence is not a sign of the need to catheterize the client, as it is a type of involuntary urine loss that occurs when the bladder contracts involuntarily and the sphincter cannot prevent leakage. Urge incontinence can be managed by using anticholinergic medications, bladder training, or pelvic floor exercises, not by catheterization.
Choice C reason: Nocturnal enuresis is not a sign of the need to catheterize the client, as it is a type of involuntary urine loss that occurs during sleep. Nocturnal enuresis can be managed by limiting fluid intake before bedtime, using an alarm device, or taking desmopressin, not by catheterization.
Choice D reason: Suprapubic discomfort is a sign of the need to catheterize the client, as it indicates bladder distension and possible urinary retention. Suprapubic discomfort can be relieved by draining the urine from the bladder using a catheter.
Correct Answer is A
Explanation
Choice A reason: This statement indicates a need for further teaching, as it is incorrect. The client does not need to catheterize the stoma, as the urine flows continuously from the ileal conduit to the pouch. Catheterization can cause infection and damage to the stoma.
Choice B reason: This statement is correct, as the client will need to measure the stoma each week for the first 6 to 8 weeks after surgery. The stoma may change in size and shape as it heals, and the client will need to adjust the size of the pouch opening accordingly.
Choice C reason: This statement is correct, as the client will always have to wear a pouch to collect the urine. The client can choose from different types of pouches, such as one-piece or two-piece systems, and change them as needed.
Choice D reason: This statement is correct, as the client will need to cleanse around the stoma with soap and water at least once a day. This helps to prevent skin irritation and infection. The client should avoid using alcohol, perfumes, or lotions on the stoma.
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