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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

Alcoholism is a common cause of hypomagnesemia due to poor dietary intake, increased renal excretion, and gastrointestinal losses. Chronic alcohol consumption leads to malnutrition and loss of magnesium through the urine, contributing to low magnesium levels.

Choice B rationale

Dehydration typically leads to hemoconcentration, which can elevate, rather than decrease, magnesium levels. Thus, it is not usually associated with low magnesium levels.

Choice C rationale

Kidney failure generally causes hypermagnesemia, not hypomagnesemia, because the kidneys cannot efficiently excrete magnesium, leading to its accumulation in the blood.

Choice D rationale

Excessive magnesium intake would result in hypermagnesemia, not hypomagnesemia, as the body accumulates more magnesium than it can excrete.

Correct Answer is []

Explanation

Condition: Myocardial infarction.

2 actions:

Administer oxygen via nasal cannula 2 L/min,

Request a prescription for aspirin 325 mg.

2 parameters:

Vital signs,

Electrocardiogram (ECG) rhythm.

Rationale for correct condition: A myocardial infarction is indicated by the elevated troponin levels and ST elevation on the ECG. The client’s symptoms of chest pain, elevated heart rate, and low oxygen saturation support this diagnosis. Prompt identification and treatment are crucial to minimize heart damage. The medical history of hypertension and coronary artery disease increases the likelihood. Immediate interventions can significantly improve outcomes.

Rationale for actions: Administer oxygen to improve oxygenation and reduce myocardial workload. Requesting aspirin helps prevent further clot formation. Morphine alleviates pain but may obscure symptoms, making it less urgent. Nitroglycerin relieves chest pain by vasodilation but is secondary. Verapamil is less immediate for acute myocardial infarction management. Vital signs reflect hemodynamic status and response to treatment. ECG rhythm detects ongoing ischemia or arrhythmias. Monitoring WBC count is less relevant acutely. Platelet count is stable; not the focus in immediate management.

Rationale for parameters: Vital signs ensure hemodynamic stability and detect hypotension or shock. ECG rhythm monitors arrhythmias and ongoing ischemia, critical in myocardial infarction. WBC count indicates infection or inflammation, less immediate concern. Platelet count is important for bleeding risks but less immediate. Chronic stable angina presents with predictable, non-severe pain. Ischemic stroke symptoms differ; focus on neurological deficits. Cardiogenic shock would present with more severe hypotension and signs of organ failure.

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A nurse is caring for a client who has diabetic ketoacidosis and hypoxia.Which of the following interventions is most critical to perform immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to the emergency department with a magnesium level of 1.2 mg/dL. The nurse is aware that a likely cause of the value is which of the following:

Correct Answer is A

Explanation

Correct Answer is []

Explanation

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