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 D
Explanation
Choice A rationale:
Numbness in the fingers is not typically a symptom of respiratory acidosis. This condition is characterized by an excess of carbon dioxide (CO2) in the body, which leads to a decrease in the pH of your blood, making it too acidic. Numbness in the fingers could be a symptom of other conditions, such as peripheral neuropathy or Raynaud’s disease.
Choice B rationale:
Abdominal pain is also not a common symptom of respiratory acidosis. While abdominal discomfort can occur in a variety of conditions, it is not directly associated with the acid-base balance disturbance that characterizes respiratory acidosis.
Conditions that commonly cause abdominal pain include gastrointestinal issues like gastritis, appendicitis, or gallstones.
Choice C rationale:
Dry skin is not a symptom of respiratory acidosis. The skin’s condition can be influenced by many factors, including hydration, environmental conditions, and certain skin conditions like eczema or psoriasis. Respiratory acidosis, on the other hand, is a condition that affects the acid-base balance in the body due to alveolar hypoventilation.
Choice D rationale:
Lethargy is indeed a symptom of respiratory acidosis. This condition occurs when the lungs can’t remove enough CO2, leading to an increase in the acidity of the blood. Symptoms of respiratory acidosis vary according to how long you’ve had the condition and its severity. Initial symptoms can include anxiety, blurred vision, and shortness of breath. If left untreated or in severe cases, symptoms may include fatigue, lethargy, delirium, or confusion. Therefore, a nurse assessing a patient with respiratory acidosis should anticipate lethargy among other symptoms.
Correct Answer is ["D"]
Explanation
Choice A rationale:
Petroleum-based ointments like Vaseline are not recommended for moisturizing lips, especially for patients on oxygen therapy. This is because petroleum jelly is not effective at restoring moisture once it’s been lost. Moreover, it can feel heavy and slippery on the lips, and it’s not very eco-friendly.
Choice B rationale:
Oxygen tanks should be kept at a safe distance from heat sources, including electric stoves. However, the recommended distance is not 4 feet but rather at least 5-10 feet away. This is to minimize the risk of fire or combustion.
Choice C rationale:
Wool blankets are not recommended when using oxygen. Wool can cause a spark which can be dangerous around oxygen. It’s important to avoid anything that may cause a spark around home oxygen, including electric heaters, electric blankets, electric razors, hair dryers, or friction toys.
Choice D rationale:
Oxygen tanks should always be stored upright. This prevents any strain on the valves or other components and reduces the risk of damage and potential gas leaks.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.