A nurse is caring for a client who has diabetic ketoacidosis and hypoxia.Which of the following interventions is most critical to perform immediately?
Perform a fingerstick glucose test to assess blood sugar levels.
Administer a bronchodilator to improve breathing.
Monitor vital signs every 15 minutes.
Assess the client's airway and ensure it is clear.
The Correct Answer is D
Choice D rationale
Ensuring a clear airway is the priority intervention in cases of diabetic ketoacidosis with hypoxia. Hypoxia refers to a deficiency in the amount of oxygen reaching tissues. Without a clear airway, oxygen cannot be effectively delivered to the lungs, and subsequently to the bloodstream and tissues. Addressing the client's airway ensures that oxygenation can be improved promptly, which is critical in preventing further complications and maintaining vital functions.
Choice A rationale
While it is important to monitor blood glucose levels in diabetic ketoacidosis, it is not the immediate priority when the client is also experiencing hypoxia. Blood glucose testing does not directly address the oxygen deficiency, which needs urgent attention to prevent severe outcomes.
Choice B rationale
Administering a bronchodilator can help improve breathing in some cases; however, it is not the first step in managing hypoxia and diabetic ketoacidosis. The primary focus should be on ensuring a patent airway to facilitate adequate oxygen delivery.
Choice C rationale
Monitoring vital signs is essential in managing any acute condition; however, in this scenario, ensuring a clear airway to address hypoxia is the most critical intervention. Monitoring alone does not resolve the immediate issue of oxygen deprivation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Nasal congestion is not a symptom associated with acute cystitis. Acute cystitis primarily affects the urinary system.
Choice B rationale
Dysuria, which means painful or difficult urination, is a common symptom of acute cystitis, as it involves inflammation of the bladder and urethra.
Choice C rationale
Shortness of breath is not a typical symptom of acute cystitis. Acute cystitis symptoms are localized to the urinary tract.
Choice D rationale
Joint pain is not associated with acute cystitis. The symptoms of acute cystitis are related to the urinary system.
Correct Answer is A
Explanation
Choice A rationale
Total parenteral nutrition (TPN) provides essential nutrients intravenously, allowing the bowel to rest and heal, which is important in the management of inflammatory bowel disease (IBD).
Choice B rationale
While reducing inflammation and controlling symptoms are important goals in IBD management, TPN is primarily used to provide nutrition and allow the bowel to rest.
Choice C rationale
Stimulating the bowel is not the purpose of TPN. TPN is used to give the digestive tract a break while ensuring the patient receives necessary nutrients.
Choice D rationale
Preventing malnutrition and promoting weight gain are secondary benefits of TPN, but the primary rationale is to provide nutrients while allowing the bowel to rest and heal.
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