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 ["B","C","F"]

Explanation

A. Administer an enema to promote bowel evacuation: Enemas increase intraluminal pressure and can worsen inflammation or risk perforation in acute diverticulitis. The bowel should be rested during the acute phase to reduce irritation and allow healing. Using an enema can aggravate symptoms and is contraindicated.

B. Prepare to insert a nasogastric tube: The client has nausea, vomiting, abdominal distention, and worsening pain, which can indicate possible ileus or obstruction associated with acute diverticulitis. An NG tube may be needed to decompress the stomach and prevent further vomiting. Preparing for NG tube insertion supports symptom management and prevents complications.

C. Ensure the client is on bed rest: Bed rest decreases bowel activity and reduces discomfort during acute diverticulitis episodes. It helps limit movement that can exacerbate abdominal pain and reduces metabolic demands while the inflammation is being treated.

D. Administer a laxative to prevent constipation: Laxatives stimulate bowel motility, which increases pressure within the colon and can worsen inflammation or risk perforation in acute diverticulitis. These medications are avoided during the acute phase to prevent exacerbation of symptoms or complications.

E. Provide the client with foods that are high in fiber: High-fiber foods help prevent future diverticulitis episodes but are not appropriate during an acute flare. Fiber increases bowel workload and irritation, worsening pain and inflammation. Dietary fiber is introduced only after acute symptoms have resolved.

F. Ensure client is NPO: Keeping the client NPO rests the bowel and reduces stimulation during acute inflammation. NPO status also prepares the client for potential procedures and reduces the risk of worsening symptoms from food intake. This is standard treatment during acute diverticulitis until symptoms improve.

G. Position client in high-Fowler's position: High-Fowler’s position is more useful for clients with respiratory compromise rather than abdominal inflammation. Although sitting upright may provide minor comfort, it does not specifically support management of acute diverticulitis. Supine or semi-Fowler's positions are better tolerated to reduce abdominal strain.

A. Use a cotton-tip applicator to relieve itching inside the cast. B. Report any drainage from the casted leg C. Keep the casted leg flat for the first 24 hr. D. Apply a heating pad to the casted leg.

Correct Answer is B

Explanation

A. Use a cotton-tip applicator to relieve itching inside the cast.: Inserting any object into the cast can damage the underlying skin, cause abrasions, or introduce infection. Scratching inside the cast may also compromise cast integrity.

B. Report any drainage from the casted leg.: Drainage can indicate bleeding, wound infection, or impaired circulation under the cast, all of which require prompt evaluation. Early reporting helps prevent complications such as compartment syndrome or infection progression.

C. Keep the casted leg flat for the first 24 hr.: Elevation, not a flat position, is recommended in the first 24 to 48 hours to minimize swelling and pain. Keeping the leg flat can increase edema, which may impair circulation and delay healing.

D. Apply a heating pad to the casted leg.: External heat should be avoided because it can cause burns under the cast where the skin cannot be directly monitored. Heat also increases blood flow and swelling, which can worsen pain and increase pressure within the cast.

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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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Correct Answer is ["B","C","F"]

Explanation

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Correct Answer is B

Explanation

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