A nurse is reviewing the medical record of a client who has developed a UTI. Which of the following findings should the nurse expect?

Choice A rationale:
The nurse should not include the statement, "If your breath smells fruity, decrease your oral intake.”. in the discharge teaching for diabetic ketoacidosis. Fruity breath odor is a sign of diabetic ketoacidosis (DKA) due to ketone production. Decreasing oral intake would not address the underlying problem, and the client should be encouraged to seek medical attention promptly if experiencing this symptom.
Choice B rationale:
This is the correct choice. The nurse should instruct the client to check their urine for ketones if their blood sugar is greater than 300 milligrams per deciliter. High blood sugar levels can lead to ketone production, and monitoring ketones in the urine can help assess the severity of DKA and guide appropriate interventions.
Choice C rationale:
The statement, "Drink one liter of fluids daily.”. is not appropriate for a client with diabetic ketoacidosis. Clients with DKA often have fluid imbalances, and their fluid needs should be assessed and managed by healthcare professionals based on individual factors and laboratory values.
Choice D rationale:
The statement, "When nausea is present, drink chilled water.”. is not specific to diabetic ketoacidosis and may not be appropriate for all clients. Nausea can be caused by various factors, and addressing the underlying cause is important. Drinking chilled water may not necessarily alleviate nausea.

Verify that the client has adequate IV access.

Choice A rationale:

Administering vasopressin to the client might be necessary to manage the hemorrhage, but before any medication administration, it is crucial to ensure the client has adequate IV access. Vasopressin is a vasoconstrictor and can help control bleeding from esophageal varices, but its effectiveness relies on IV access to deliver the medication promptly.

Choice B rationale:

Requesting blood from the blood bank is essential for a client experiencing significant bleeding. However, the priority action is to verify IV access to administer any necessary blood products.

Choice C rationale:

This is the correct choice. Before initiating any interventions, ensuring the client has appropriate IV access is a priority. Adequate IV access is necessary to administer fluids, medications, or blood products promptly and effectively stabilize the client's blood pressure.

Choice D rationale:

Inserting an indwelling urinary catheter is not the priority action in this situation. While monitoring urine output is important, it should be secondary to addressing the client's hypotension and hemorrhage.