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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Related Questions
Correct Answer is C
Explanation
Choice A rationale
Administering insulin when the breakfast tray arrives may not provide sufficient time for the insulin to take effect before the client begins eating, potentially leading to hyperglycemia.
Choice B rationale
Administering insulin at 07: is too early and may result in hypoglycemia before the client eats breakfast.
Choice C rationale
Administering insulin at 07: allows sufficient time for the insulin to take effect before the client eats breakfast, helping to maintain appropriate blood glucose levels.
Choice D rationale
Administering insulin 30 minutes after breakfast is too late and could result in hyperglycemia since the client would have already consumed carbohydrates.
Correct Answer is C
Explanation
Choice A rationale
Jaundice is not commonly associated with Crohn's disease; it is more related to liver or gallbladder issues.
Choice B rationale
Hypertension is not a common symptom of Crohn's disease. It is generally associated with other conditions such as cardiovascular disease.
Choice C rationale
Abdominal pain and cramping are hallmark symptoms of Crohn's disease due to inflammation in the gastrointestinal tract.
Choice D rationale
Weight loss, rather than weight gain, is typically associated with Crohn's disease due to malabsorption and chronic inflammation.
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