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 ["31"]
Explanation
Step 1 is: Convert hours to minutes: 8 hours × 60 minutes/hour = 480 minutes.
Step 2 is: Calculate the drops/minute: (1000 mL ÷ 480 minutes) × 15 gtts/mL.
Step 3 is: Perform the division: 1000 mL ÷ 480 minutes ≈ 2.0833 mL/min.
Step 4 is: Perform the multiplication: 2.0833 mL/min × 15 gtts/mL ≈ 31.25 drops/min.
Step 5 is: Round the answer to the nearest whole number: 31 drops/min.
Final calculated answer: 31 drops/min.
Correct Answer is A
Explanation
Choice A rationale
Using the inhaler before engaging in physical activity helps to prevent exercise-induced bronchospasm, which is common in patients with COPD.
Choice B rationale
Skipping doses if symptoms improve is not recommended as it can lead to suboptimal control of COPD and potential exacerbations.
Choice C rationale
Using the inhaler only when experiencing severe symptoms is not effective in managing COPD. Regular use as prescribed helps maintain lung function and prevent exacerbations.
Choice D rationale
Doubling the dose if symptoms do not improve immediately is not safe and can lead to adverse effects. Patients should follow the prescribed dosage and consult their healthcare provider if symptoms persist.
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