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: 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.

Choice A: Determine the client’s calcium level. This is the priority action for the nurse to take because the client might have hypocalcemia, which is a low level of calcium in the blood. Hypocalcemia can occur after a thyroidectomy due to accidental removal or damage of the parathyroid glands, which regulate calcium levels. Hypocalcemia can cause muscle spasms, tetany, paresthesia, and seizures.

Choice B: Give the client an oral potassium supplement. This is not an appropriate action for the nurse to take because the client might have hyperkalemia, which is a high level of potassium in the blood. Hyperkalemia can also occur after a thyroidectomy due to damage to the adrenal glands, which regulate potassium levels. Hyperkalemia can cause muscle weakness, arrhythmias, and cardiac arrest.

Choice C: Administer intravenous normal saline solution. This is not a necessary action for the nurse to take because the client does not have signs of dehydration or fluid imbalance. Normal saline solution does not affect calcium or potassium levels.

Choice D: Monitor the client’s peripheral pulses. This is an important action for the nurse to take, but not the priority. The nurse should monitor the client’s peripheral pulses for signs of decreased perfusion or ischemia, which can result from hypocalcemia or hyperkalemia affecting the cardiac function. However, this should be done after determining the client’s calcium level and correcting it if needed.