A nurse is caring for a client who has diabetic ketoacidosis and hypoxia.
Which of the following actions should the nurse take first?

Choice A rationale

Acetaminophen can be hepatotoxic in clients with liver damage, so it should be avoided. This is especially critical for clients with cirrhosis, where liver function is already compromised.

Choice B rationale

Eating three large meals can be overwhelming for someone with cirrhosis, as the liver is less able to process nutrients efficiently. Smaller, more frequent meals are advised.

Choice C rationale

Avoiding high-sodium foods is crucial because cirrhosis often leads to fluid retention and ascites, which can be exacerbated by a high-sodium diet.

Choice D rationale

Increasing activity as much as possible may not be safe for someone with cirrhosis, who often experiences fatigue and muscle wasting. Activity should be balanced with rest and tolerance levels.

Choice A rationale

Withholding oral fluids and food is the priority because it reduces pancreatic stimulation and decreases the secretion of pancreatic enzymes, preventing further autodigestion and inflammation of the pancreas.

Choice B rationale

Auscultating the client's lungs is important to check for complications such as pleural effusion or atelectasis, but it is not the immediate priority after pain management.

Choice C rationale

Assisting the client to a side-lying position can help with comfort and may ease breathing, but it does not directly address the underlying issue of pancreatic inflammation.

Choice D rationale

Providing oral hygiene is essential for overall care but does not impact the acute management of pancreatitis.