A nurse is reinforcing discharge teaching with the family of an older adult client about safety precautions when administering a hypotonic enema to the client. Which of the following instructions should the nurse include in the teaching?

Choice A Reason:

Clammy skin is incorrect. DKA is more likely to cause dry or flushed skin due to dehydration and the effects of high blood sugar levels. Clammy skin is usually associated with conditions that cause excessive sweating.

Choice B Reason:

Bounding pulse is incorrect. DKA can lead to tachycardia (a rapid heart rate) as the body tries to compensate for the metabolic imbalances, but a bounding pulse is not a characteristic finding of DKA.

Choice C Reason:

Elevated blood pressure is incorrect. DKA is more likely to result in an initial decrease in blood pressure due to dehydration. Elevated blood pressure may be present in other conditions but is not a primary feature of DKA.

Choice D Reason:

Fruity breath odor is correct. Diabetic ketoacidosis (DKA) is a serious complication of diabetes characterized by a buildup of ketones in the blood, which results from the body breaking down fat for energy due to a lack of insulin. Fruity breath odor, often described as smelling like acetone or nail polish remover, is a classic sign of DKA. It occurs because the presence of ketones in the blood leads to the exhalation of acetone through the breath.

Choice A Reason:

Maintaining the client in high-Fowler's position is a correct action. Keeping the client in a high-Fowler's position (sitting up with the head of the bed elevated) can help improve lung expansion and ease breathing for clients with heart failure and respiratory distress.

Choice B Reason:

Instructing the client to cough every 4 hr. is not directly addressing the underlying issue of fluid accumulation and respiratory distress associated with heart failure. Coughing alone may not be sufficient to alleviate these symptoms.

Choice C Reason:

Increasing the client's intake of oral fluids is generally not recommended without considering the client's overall fluid status. In heart failure, there is often a need to restrict fluid intake to prevent fluid overload and worsening of symptoms. Increasing oral fluids should be done cautiously and under the guidance of the healthcare provider.

Choice D Reason:

Encouraging the client to ambulate to loosen secretions. While ambulation can be beneficial for some clients to improve overall circulation and prevent complications, it may not be the primary intervention in this case. The client's primary issue is likely related to pulmonary congestion due to heart failure, and they may be too short of breath to ambulate effectively.