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 B
Explanation
Choice A reason: Metabolic alkalosis is a condition in which the blood pH is elevated due to an excess of bicarbonate or a loss of acid. It can be caused by vomiting, diuretics, or excessive antacid intake. It is not associated with COPD.
Choice B reason: Respiratory acidosis is a condition in which the blood pH is lowered due to an accumulation of carbon dioxide. It can be caused by hypoventilation, airway obstruction, or lung diseases such as COPD. It is the most common acid-base imbalance in COPD patients.
Choice C reason: Respiratory alkalosis is a condition in which the blood pH is elevated due to a loss of carbon dioxide. It can be caused by hyperventilation, anxiety, fever, or aspirin overdose. It is not common in COPD patients.
Choice D reason: Metabolic acidosis is a condition in which the blood pH is lowered due to an excess of acid or a loss of bicarbonate. It can be caused by diabetic ketoacidosis, renal failure, or lactic acidosis. It is not directly related to COPD.
Correct Answer is A,B,C,D
Explanation
Choice A reason: Confirming the client's identity by checking their wristband is the first step to ensure that the right client receives the right treatment.
Choice B reason: Providing for the client's privacy by closing the curtains is the second step to respect the client's dignity and comfort.
Choice C reason: Assisting the client into the Sims' position is the third step to facilitate the insertion of the enema tubing and the flow of the solution. The Sims' position is a side-lying position with the upper leg flexed and the lower leg straight.
Choice D reason: Inserting the tip of the enema tubing into the client's rectum is the fourth and final step to administer the enema. The nurse should lubricate the tip of the tubing, gently insert it about 3 to 4 inches into the rectum, and release the clamp to allow the solution to flow. The nurse should monitor the client for any signs of discomfort or cramping and adjust the flow rate accordingly.
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