A client with a history of a right radical mastectomy arrives on the postoperative unit following surgical repair of a fractured left radius and application of a short arm cast. Which action should the practical nurse implement while obtaining the client's blood pressure (BP)?

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: Water-based lubricant is essential during a Pap test to ensure the patient's comfort and ease the insertion of the speculum. It is non-irritating and does not interfere with the collection of the cervical sample, which is crucial for accurate test results.
Choice B reason: A specimen bottle is required to store and transport the collected cervical cells to the laboratory for analysis. It ensures that the sample is properly preserved and can be accurately analyzed for any abnormalities, such as precancerous or cancerous cells.
Choice C reason: A microscopic slide and spray cell fixative are necessary for preparing the collected cervical cells for microscopic examination. The fixative helps preserve the cells on the slide, preventing them from drying out or becoming damaged, which is important for accurate analysis.
Choice D reason: A disposable vaginal speculum is used to gently open the vaginal walls, providing the healthcare provider with a clear view of the cervix. This allows for the proper collection of cervical cells during the Pap test, ensuring the accuracy and reliability of the test results.
Choice E reason: A cytobrush or plastic spatula cervical sampling device is used to collect the cervical cells from the transformation zone of the cervix. These devices are designed to gather an adequate and representative sample, which is essential for the accurate detection of any cellular abnormalities.