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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Collecting urine from the catheter’s port is not the correct procedure when collecting a urine specimen for culture and sensitivity through straight catheterization. The port is not a sterile environment and could contaminate the specimen, leading to inaccurate results.
Choice B rationale:
Using a sterile specimen container is the correct procedure. This ensures that the specimen is not contaminated by any external bacteria or substances, which could affect the results of the culture and sensitivity test. The container must be sterile to prevent the growth of microbes that are not present in the urine sample. This helps to ensure that the results of the culture are accurate and reflect the microbes present in the urine, not those introduced during collection.
Choice C rationale:
Inflating the balloon with sterile water is not a step in this procedure. The balloon is part of an indwelling catheter, not a straight catheter. An indwelling catheter remains in the bladder for a longer period, and the balloon is inflated to keep it in place. A straight catheter is used for a single voiding or to obtain a sterile urine specimen.
Choice D rationale:
Instructing the patient to clean from front to back with an antiseptic solution is not a step in this procedure. While maintaining cleanliness is important, this specific instruction is more relevant to a clean-catch midstream urine specimen, not a specimen collected through straight catheterization.
Correct Answer is A
Explanation
Choice A rationale:
Metabolic alkalosis is an acid-base imbalance characterized by excessive loss of acid or excessive gain of bicarbonate produced by an underlying pathologic disorder. It causes metabolic, respiratory, and renal responses, producing characteristic symptoms. One of the manifestations of metabolic alkalosis is cardiovascular abnormalities, such as atrial tachycardia. Therefore, placing the patient on continuous cardiac monitoring is a necessary action to assess the patient’s heart rate and rhythm and detect any abnormalities early.
Choice B rationale:
Insulin is not typically used in the treatment of metabolic alkalosis. Insulin is a hormone that regulates blood sugar levels. It’s not directly related to the body’s acid-base balance. Therefore, obtaining a prescription for insulin for the patient would not be a relevant action in this case.
Choice C rationale:
Administering sodium bicarbonate to a patient with metabolic alkalosis would not be appropriate. Sodium bicarbonate is a base and is often used to treat metabolic acidosis, a condition characterized by an excess of acid in the body. Giving sodium bicarbonate to a patient with metabolic alkalosis, a condition characterized by an excess of base in the body, could potentially worsen the patient’s condition.
Choice D rationale:
Having the patient breathe into a paper bag is a common treatment for respiratory alkalosis, not metabolic alkalosis.
Respiratory alkalosis is caused by hyperventilation, which leads to a decrease in carbon dioxide in the blood. Breathing into a paper bag helps to increase the amount of carbon dioxide the person inhales, helping to restore the acid-base balance. However, metabolic alkalosis is not caused by hyperventilation, so this treatment
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