A nurse is caring for a patient with diabetic ketoacidosis and hypoxia.
What is the first action the nurse should take?

Obtain a prescription to administer insulin.

Obtain a prescription for supplemental oxygen.

Obtain a prescription to check the patient’s glucose level.

Obtain a prescription to administer intravenous fluids.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Administering insulin is a crucial step in managing diabetic ketoacidosis (DKA), as insulin deficiency is a primary cause of DKA12. However, it is not the first action to take when a patient presents with both DKA and hypoxia. While insulin helps to reduce blood glucose levels and suppress the production of ketones, it does not address the immediate life-threatening condition of hypoxia.

Choice B rationale:

Hypoxia, or low levels of oxygen in the body, is a medical emergency that requires immediate attention. Supplemental oxygen can help increase the oxygen levels in the patient’s blood, thereby alleviating hypoxia. In the context of a patient with DKA and hypoxia, providing supplemental oxygen would be the first action to take to stabilize the patient’s condition before addressing the DKA12.

Choice C rationale:

Checking the patient’s glucose level is an important part of managing DKA, as hyperglycemia is a key feature of this condition. However, it is not the first action to take in this scenario. While monitoring glucose levels can guide the administration of insulin and other treatments for DKA, it does not address the immediate threat posed by hypoxia.

Choice D rationale:

Administering intravenous fluids is another important step in managing DKA12. Dehydration is a common complication of DKA due to excessive urination caused by high blood sugar levels. However, similar to Choices A and C, while it is an important part of treatment, it is not the first action to take when a patient presents with both DKA and hypoxia.

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Correct Answer is A

Explanation

The correct answer is choice A.

Choice A rationale: Assisting the patient to the bathroom every 2 hours is a fixed schedule that doesn't allow for individual variations in bladder function. A bladder-training program should encourage the patient to recognize and respond to their own urge to urinate, promoting self-reliance and bladder control.

Choice B rationale: Offering the opportunity to urinate before bathing is a good practice to prevent accidents and promote comfort. It also helps to reduce the risk of urinary tract infections.

Choice C rationale: Encouraging the patient to urinate when they feel the urge is a key component of bladder training. It helps the patient to develop bladder control and reduce the frequency of accidents.

A. I do my wheelchair exercises sitting in my chair. B. I use a suppository every night to have a bowel movement. C. I need to catheterize myself twice a day. D. I carry a water bottle with me because I drink a lot of water.

Correct Answer is C

Explanation

Choice A rationale:

The statement “I do my wheelchair exercises sitting in my chair” is correct. Wheelchair exercises are designed to be performed while seated in a wheelchair. They help to maintain muscle strength and flexibility, which is crucial for individuals with paralysis.

Choice B rationale:

The statement “I use a suppository every night to have a bowel movement” is also correct. Individuals with paralysis often have difficulty with bowel movements due to lack of muscle control. Using a suppository can stimulate the rectum and induce a bowel movement. Choice C rationale:

The statement “I need to catheterize myself twice a day” indicates a need for further teaching. Individuals with paralysis from the waist down following a spinal cord injury typically need to perform intermittent self-catheterization every 4-6 hours, not just twice a day. This helps to prevent urinary tract infections and bladder overdistension.

Choice D rationale:

The statement “I carry a water bottle with me because I drink a lot of water” is correct. Drinking plenty of water is important for overall health and can help to prevent urinary tract infections, which are common in individuals who self-catheterize.

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A nurse is caring for a patient with diabetic ketoacidosis and hypoxia. What is the first action the nurse should take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is implementing a bladder-training program for a patient. Which of the following actions by the assistive personnel (AP) assisting with the patient’s care should the nurse intervene?

Correct Answer is A

Explanation

A nurse is reinforcing teaching about elimination with an adolescent who is paralyzed from the waist down following a spinal cord injury. Which statement by the adolescent indicates a need for further teaching?

Correct Answer is C

Explanation

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A nurse is caring for a client who has paraplegia and is on an intermittent urinary catheterization program. Which of the following findings indicates to the nurse the need to catheterize the client?

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A nurse is caring for a patient with diabetic ketoacidosis and hypoxia.
What is the first action the nurse should take?