A nurse is caring for a client who has diabetic ketoacidosis and hypoxia.Which of the following interventions is most critical to perform immediately?
Perform a fingerstick glucose test to assess blood sugar levels.
Administer a bronchodilator to improve breathing.
Monitor vital signs every 15 minutes.
Assess the client's airway and ensure it is clear.
The Correct Answer is D
Choice D rationale
Ensuring a clear airway is the priority intervention in cases of diabetic ketoacidosis with hypoxia. Hypoxia refers to a deficiency in the amount of oxygen reaching tissues. Without a clear airway, oxygen cannot be effectively delivered to the lungs, and subsequently to the bloodstream and tissues. Addressing the client's airway ensures that oxygenation can be improved promptly, which is critical in preventing further complications and maintaining vital functions.
Choice A rationale
While it is important to monitor blood glucose levels in diabetic ketoacidosis, it is not the immediate priority when the client is also experiencing hypoxia. Blood glucose testing does not directly address the oxygen deficiency, which needs urgent attention to prevent severe outcomes.
Choice B rationale
Administering a bronchodilator can help improve breathing in some cases; however, it is not the first step in managing hypoxia and diabetic ketoacidosis. The primary focus should be on ensuring a patent airway to facilitate adequate oxygen delivery.
Choice C rationale
Monitoring vital signs is essential in managing any acute condition; however, in this scenario, ensuring a clear airway to address hypoxia is the most critical intervention. Monitoring alone does not resolve the immediate issue of oxygen deprivation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Hypertension is not a typical finding associated with community-acquired pneumonia. The condition more commonly presents with respiratory symptoms such as cough, fever, and difficulty breathing.
Choice B rationale
Unequal pupils are not a common finding in community-acquired pneumonia and could indicate a neurological issue or head injury, which would require further investigation.
Choice C rationale
Confusion, particularly in older adults, can be a symptom of community-acquired pneumonia. It is often due to hypoxia or systemic inflammation and is a sign of a more severe infection.
Choice D rationale
Tympany upon chest percussion is not expected in pneumonia. Pneumonia typically presents with dullness on percussion due to the consolidation of lung tissue, not the hyperresonance that causes tympany.
Correct Answer is A
Explanation
Choice A rationale
A terminal ileostomy involves creating an opening in the right lower quadrant of the abdomen where the ileum is brought to the surface to form a stoma for waste elimination.
Choice B rationale
The left lower quadrant is not used for a terminal ileostomy, as it is not anatomically appropriate for the ileum.
Choice C rationale
The right upper quadrant is not relevant to a terminal ileostomy because the ileum is located in the lower part of the abdomen.
Choice D rationale
The left upper quadrant is also inappropriate for a terminal ileostomy due to the anatomical position of the ileum.
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