A client is being transferred from the cardiovascular intensive care unit (CV-ICU) three days after a myocardial infarction. Which information is most significant in planning this client's rehabilitation?

Choice A reason: Assessing urine for ketones is an important step in diagnosing diabetic ketoacidosis (DKA), a serious complication of diabetes. Ketones are produced when the body breaks down fat for energy due to a lack of insulin. High levels of ketones in the urine can indicate DKA. However, while this is a necessary assessment, it is not the immediate priority. The most urgent action is to measure the blood glucose to determine if hyperglycemia is present, which is a key indicator of DKA.
Choice B reason: Auscultating breath sounds is an important assessment to evaluate the client's respiratory status. Deep, rapid respirations (Kussmaul respirations) are often associated with DKA as the body attempts to compensate for metabolic acidosis. While auscultating breath sounds is valuable, it is not the first action to take. The primary concern is to confirm hyperglycemia, which is a critical step in diagnosing and managing DKA.
Choice C reason: Elevating the head of the bed can help improve the client's comfort and respiratory function, especially if they are experiencing difficulty breathing. However, this action does not directly address the underlying issue of hyperglycemia and potential DKA. While it can be part of supportive care, the immediate priority is to measure the blood glucose levels to assess the severity of the condition and initiate appropriate treatment.
Choice D reason: Measuring the blood glucose is the most critical and immediate action. Deep, rapid respirations and a fruity breath odor are classic signs of DKA, a life-threatening condition that requires prompt diagnosis and treatment. By measuring the blood glucose, the practical nurse can confirm hyperglycemia and initiate interventions to manage blood sugar levels, such as insulin administration and fluid replacement. Early detection and treatment are essential to prevent complications and stabilize the client’s condition.

Choice A reason: Commending the client for ensuring an adequate source of vitamin C in the diet is not the best response. While vitamin C is important for overall health, it does not directly impact bone density. The client's focus on orange juice may stem from a misunderstanding of the nutrients that are critical for bone health, such as calcium and vitamin D. A better approach would be to address the specific nutrients that support bone density and clarify any misconceptions.
Choice B reason: Advising the client of the need to remain NPO (nothing by mouth) until the test is completed is not necessary for a bone density test. Bone density tests, such as dual-energy X-ray absorptiometry (DEXA) scans, do not require the client to fast beforehand. Providing this advice would be incorrect and could cause unnecessary concern or confusion for the client.
Choice C reason: Determining if the client drinks orange juice that has been fortified with calcium is a helpful step, but it does not address the immediate need to correct the client's misunderstanding about the purpose of the bone density test. While calcium-fortified orange juice can be beneficial for bone health, the priority should be to ensure the client has accurate information about the test they are undergoing.
Choice D reason: Correcting the client's misunderstanding of the purpose of bone density testing is the most appropriate response. The primary goal of a bone density test is to measure the density of the bones and assess the risk of fractures, not to diagnose or confirm the presence of osteoporosis. By providing clear and accurate information about the test, the practical nurse can help the client understand its purpose and alleviate any misconceptions. This response also opens the door for further education on managing osteoporosis and ensuring the client is receiving the necessary nutrients for bone health.