A nurse is caring for a client with a new diagnosis of heart failure. Which of the following dietary recommendations should the nurse provide?

Choice A reason: Administering insulin infusion is the priority in DKA to correct hyperglycemia and halt ketogenesis. Insulin lowers blood glucose by facilitating cellular uptake and inhibits lipolysis, reducing ketone production. This addresses the underlying metabolic derangement, preventing further acidosis and stabilizing the patient’s condition rapidly, critical for life-threatening DKA.

Choice B reason: Providing oral glucose is contraindicated in DKA, as the client already has severe hyperglycemia. Adding glucose would worsen the condition, increasing osmotic diuresis and acidosis. The focus is on lowering blood sugar with insulin and fluids, not adding more glucose, which could exacerbate dehydration and metabolic imbalance.

Choice C reason: Sodium bicarbonate may be used in severe DKA with profound acidosis (pH < 7.0), but it is not the priority. Insulin and fluid resuscitation correct the underlying cause of acidosis by stopping ketone production and restoring perfusion. Bicarbonate is an adjunct and may cause complications like hypokalemia if used prematurely.

Choice D reason: Deep breathing exercises do not address the metabolic cause of DKA. While compensatory hyperventilation (Kussmaul respirations) occurs to correct acidosis, encouraging breathing exercises does not treat hyperglycemia or ketosis. Insulin and fluids are critical to reverse the underlying pathology, making breathing exercises a low-priority intervention in this acute condition.

Choice A reason: Frequent skin assessments allow early detection of pressure injury signs, such as non-blanchable redness or skin breakdown. By identifying at-risk areas like the sacrum or heels, nurses can implement preventive measures promptly. This reduces tissue ischemia from prolonged pressure, preventing progression to ulcers by ensuring timely intervention to protect skin integrity.

Choice B reason: Frequent turning and positioning relieve pressure on bony prominences, reducing ischemia and tissue damage. Repositioning every 2 hours promotes blood flow, preventing prolonged compression of capillaries, which leads to hypoxia and necrosis. This is a cornerstone of pressure injury prevention, especially in immobile patients with limited tissue perfusion.

Choice C reason: Optimizing nutrition ensures adequate protein and micronutrient intake, essential for tissue repair and maintenance. Malnutrition impairs collagen synthesis and immune function, increasing susceptibility to skin breakdown. Adequate caloric and protein intake supports skin integrity, reducing the risk of pressure injuries by enhancing tissue resilience and healing capacity.

Choice D reason: Maintaining the head of the bed at a 45-degree angle increases shear forces on the sacrum and coccyx, potentially exacerbating pressure injury risk. While it may aid respiratory function, it does not directly prevent pressure injuries and may contribute to skin breakdown in immobile patients due to increased frictional forces.

Choice E reason: Inspecting the sacrum for blanching is part of skin assessment but is not an intervention to reduce incidence. Blanching indicates intact capillary perfusion, but non-blanchable redness signals early damage. While useful for staging, it is a diagnostic step, not a preventive measure like repositioning or nutrition, which actively reduce pressure injury risk.