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.

Answer and Explanation

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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Correct Answer is B

Explanation

Choice B rationale

Radiating pain to the left arm is a classic symptom of a myocardial infarction (MI). This pain occurs due to the heart muscle not receiving enough oxygen, often because of a blockage in one or more coronary arteries. The pain can radiate to the left arm, jaw, neck, or back, and is a key indicator for diagnosing an MI.

Choice A rationale

Nausea and vomiting can occur during an MI but are not the most distinctive symptoms for diagnosis. They can also be associated with other conditions, making them less specific indicators of MI.

Choice C rationale

Shortness of breath is a common symptom during an MI, resulting from reduced oxygen supply to the heart. However, while it is an important clinical manifestation, it can also be associated with other cardiac or respiratory conditions.

Choice D rationale

Headache is not a typical symptom of an MI. It is less commonly associated with heart attacks and can be caused by a wide range of other factors, making it an unreliable symptom for diagnosing MI.

A. A. Visible signs of bone healing on an X-ray. B. Increased swelling and redness in the right hip. C. Improved range of motion in the right hip. D. Decrease in hip pain.

Correct Answer is D

Explanation

Choice A rationale

Visible signs of bone healing on an X-ray would not be expected after Buck's traction. Healing takes longer to become visible on an X-ray.

Choice B rationale

Increased swelling and redness would indicate complications such as infection or thrombophlebitis, not the effectiveness of traction.

Choice C rationale

Improved range of motion would not typically be expected while Buck's traction is in place. The primary purpose is to reduce pain and immobilize the fracture.

Choice D rationale

Decrease in hip pain is a direct indicator of the effectiveness of Buck's traction in alleviating symptoms and preventing further injury to the fractured femur.

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A nurse is caring for a client who has diabetic ketoacidosis and hypoxia.Which of the following interventions is most critical to perform immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following clinical manifestations would make the nurse suspect the client is experiencing a myocardial infarction (MI)?

Correct Answer is B

Explanation

Which assessment finding should the nurse expect to observe when evaluating the effectiveness of Buck's traction for a patient who has an intracapsular fracture of the right femur?

Correct Answer is D

Explanation

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