A nurse is collecting data from a client who has diabetes mellitus. Which of the following findings indicates that the client is experiencing DKA?

Choice A: Measure the tube for insertion from the tip of the nose to the umbilicus. This is not an intervention that the nurse should take when inserting a nasogastric tube. The nurse should measure the tube for insertion from the tip of the nose to the earlobe and then to the xiphoid process, which is a more accurate way of estimating the length of the tube needed to reach the stomach.

Choice B: Place the client in a supine position. This is not an intervention that the nurse should take when inserting a nasogastric tube. The nurse should place the client in a high-Fowler’s position, which is a position with the head of the bed elevated to 90 degrees. This position can prevent aspiration, promote breathing, and allow gravity to assist with the insertion of the tube.

Choice C: Withdraw the tube if the client gags during insertion. This is not an intervention that the nurse should take when inserting a nasogastric tube. The nurse should not withdraw the tube if the client gags during insertion, as this can cause trauma to the nasal or pharyngeal mucosa and increase discomfort. The nurse should pause and allow the client to rest and breathe until gagging subsides, then resume insertion. The nurse should also provide reassurance and encouragement to the client throughout the procedure.

Choice D: Instruct the client to place his chin to his chest and swallow. This is an intervention that the nurse should take when inserting a nasogastric tube, which is a flexible tube that is inserted through the nose and into the stomach. The nurse should instruct the client to place his chin to his chest and swallow as the tube passes through the pharynx and into the esophagus. This can facilitate the insertion of the tube and prevent it from entering the trachea or causing injury to the nasal or pharyngeal mucosa.

Choice A: Obtain the client’s vital signs. This is an important nursing action, but not the priority. The nurse should monitor the client’s vital signs for signs of infection, fluid imbalance, or shock, but these are not as urgent as relieving the client’s pain.

Choice B: Weigh the client. This is a necessary nursing action, but not the priority. The nurse should weigh the client daily to assess their fluid status and nutritional needs, but this can be done after addressing the client’s pain.

Choice C: Administer pain medication. This is the priority nursing action because the nurse should follow the principle of Maslow’s hierarchy of needs and address the client’s physiological needs first. Pain can interfere with the client’s healing process and affect their quality of life.

Choice D: Change the client’s dressing. This is a required nursing action, but not the priority. The nurse should change the client’s dressing to prevent infection and promote wound healing, but this can be done after administering pain medication to make the procedure more comfortable for the client.