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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["31"]
Explanation
Step 1 is: Convert hours to minutes: 8 hours × 60 minutes/hour = 480 minutes.
Step 2 is: Calculate the drops/minute: (1000 mL ÷ 480 minutes) × 15 gtts/mL.
Step 3 is: Perform the division: 1000 mL ÷ 480 minutes ≈ 2.0833 mL/min.
Step 4 is: Perform the multiplication: 2.0833 mL/min × 15 gtts/mL ≈ 31.25 drops/min.
Step 5 is: Round the answer to the nearest whole number: 31 drops/min.
Final calculated answer: 31 drops/min.
Correct Answer is C
Explanation
Choice A rationale
Fluticasone is a corticosteroid used to manage asthma and COPD symptoms and does not typically require clarification.
Choice B rationale
Furosemide is a diuretic used to manage fluid overload in heart failure and does not require clarification.
Choice C rationale
Carvedilol is a non-selective beta-blocker that can exacerbate asthma symptoms and bronchospasm. It should be avoided in clients with a history of asthma.
Choice D rationale
Isosorbide dinitrate is a nitrate used to manage angina and heart failure and does not require clarification.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.