A nurse in an emergency department is caring for a client whose blood glucose level indicates diabetic ketoacidosis. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Monitor for pulmonary edema

Administer prescribed IV fluids

Assess vital signs to determine hydration status.

Check the client's airway and level of consciousness.

Answer and Explanation

The Correct Answer is D,C,B,A

A. Monitor for pulmonary edema: Monitoring for pulmonary edema is important during fluid replacement to detect complications from rapid IV infusion. However, it is performed after initial stabilization, fluid administration, and ongoing assessment rather than as the first step.

B. Administer prescribed IV fluids: IV fluid administration is critical for correcting dehydration and restoring perfusion in DKA. This step follows the initial assessment of airway and vital signs to ensure safe and effective fluid resuscitation.

C. Assess vital signs to determine hydration status: Assessing vital signs helps identify the degree of hypovolemia and guides the rate and type of fluid replacement. This assessment occurs immediately after ensuring the airway is patent and the client is responsive.

D. Check the client's airway and level of consciousness: The first priority in DKA is to ensure airway patency and evaluate neurological status. Changes in consciousness may indicate severe hyperglycemia, electrolyte imbalance, or hypoperfusion, and addressing airway concerns takes precedence before other interventions.

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Correct Answer is A

Explanation

A. Notify the fire department that oxygen is in use in the home.: Informing the local fire department ensures they are aware of the increased fire risk and can respond appropriately in case of an emergency. Home oxygen increases combustion potential, and early notification enhances overall household safety planning.

B. Increase the oxygen flow rate by 1 L if the client experiences dyspnea.: Changing oxygen flow rates without a prescription is unsafe because it can lead to CO₂ retention in some clients or inadequate oxygenation in others. Any adjustment to oxygen therapy must be made only by the provider to avoid complications.

C. Store oxygen tanks on their side when not in use.: Oxygen tanks should always be stored upright and secured to prevent rolling or falling, which could cause tank rupture or high-pressure release.

D. Replace the cotton blankets with wool and synthetic blankets.: Wool and synthetic materials can generate static electricity, which poses an ignition risk around oxygen. Cotton blankets are the safer option because they reduce friction and minimize static buildup.

A. Decrease traction on the catheter B. Remove the indwelling urinary catheter. C. Administer ibuprofen 400 mg for pain relief. D. Flush the catheter manually with 0.9% sodium chloride.

Correct Answer is D

Explanation

A. Decrease traction on the catheter: Traction is applied to maintain pressure on the prostatic fossa after surgery and should not be adjusted without provider instruction. Reducing traction does not address the cause of bladder spasms or decreased output, which is most often related to catheter obstruction from clots.

B. Remove the indwelling urinary catheter: Removing the catheter is not appropriate because it interrupts continuous bladder irrigation and can worsen bleeding. Catheter removal should only occur under provider direction, especially in the early postoperative period when clot formation is common.

C. Administer ibuprofen 400 mg for pain relief: Ibuprofen may help relieve discomfort, but it does not correct the cause of bladder spasms or low urinary output. Pain control alone is inadequate when obstruction is suspected, and relying on analgesics may delay necessary interventions.

D. Flush the catheter manually with 0.9% sodium chloride: Manual irrigation helps clear clots that can obstruct the catheter, restoring urinary flow and relieving bladder spasms. This is the most appropriate intervention when output suddenly decreases during continuous bladder irrigation, as obstruction is a common postoperative complication.

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A nurse in an emergency department is caring for a client whose blood glucose level indicates diabetic ketoacidosis. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Nursing Test Bank

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