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

Choice A rationale:

The stool guaiac test does not check for bacteria in the feces. This test is used to detect hidden (occult) blood in a stool sample. It is the most common type of fecal occult blood test (FOBT)1.

Choice B rationale:

The stool guaiac test does not check for fat in the feces. The presence of fat in the feces is usually checked by a different test called a fecal fat test. The stool guaiac test is specifically designed to detect the presence of hidden blood in the stool.

Choice C rationale:

The stool guaiac test does not check for parasites in the feces. Parasites are typically detected using a stool ova and parasites (O&P) test. The stool guaiac test is used to detect hidden blood in the stool, which could be an indication of various conditions, including colon cancer or polyps in the colon or rectum.

Choice D rationale:

The stool guaiac test checks for hidden blood in the feces. This is the correct answer. The test can find blood even if you cannot see it yourself. Occult blood in the stool may indicate colon cancer or polyps in the colon or rectum, though not all cancers or polyps bleed. If blood is detected through a fecal occult blood test, additional tests may be needed to determine the source of the bleeding. The stool guaiac test can only detect the presence or absence of blood — it can’t determine what’s causing the bleeding.

Choice A rationale:

Crackles are a common symptom of pleural effusion. They are abnormal lung sounds that are heard when a patient with pleural effusion breathes in. The sound is caused by the opening of small airways and alveoli collapsed by fluid, exudate, or lack of aeration during expiration.

Choice B rationale:

Crepitus is not typically associated with pleural effusion. Crepitus is a crackling or grating sound or feeling produced by air in subcutaneous tissue or by the rubbing together of fragments of broken bone. In the context of respiratory health, crepitus might be felt if there is subcutaneous emphysema, where air gets into tissues under the skin covering the chest wall or neck.

Choice C rationale:

Substernal retractions are not a typical symptom of pleural effusion. Retractions are a sign of respiratory distress, but they are more commonly associated with conditions that cause upper airway obstruction or severe lung disease, such as asthma or pneumonia. Choice D rationale:

Dullness upon percussion is a classic sign of pleural effusion. When there is fluid in the pleural space, it prevents the normal resonant sound produced by the air-filled lungs from being heard. Instead, a dull sound is heard when the chest is percussed.