A nurse is caring for a client with diabetes who presents with elevated blood sugar levels and excessive thirst. The nurse understands that these symptoms are primarily caused by:

Choice A rationale:

The nurse should suspect tension pneumothorax in the patient with a chest tube who shows sudden decreased drainage, pink frothy sputum, and crackles on auscultation. Tension pneumothorax is a life-threatening condition where air accumulates in the pleural space, leading to increased pressure on the affected lung and heart. Immediate intervention, such as chest tube insertion on the affected side, is crucial to relieve the pressure and improve ventilation.

Choice B rationale:

Subcutaneous emphysema does not present with decreased drainage or pink frothy sputum. It is characterized by air trapped under the skin, causing a crackling sensation on palpation. Monitoring respiratory status and elevating the head of the bed are appropriate interventions for subcutaneous emphysema but not in this scenario.

Choice C rationale:

Re-expansion pulmonary edema is a rare complication that occurs after rapid lung re-expansion. It does not typically manifest with pink frothy sputum and crackles. Administering diuretics may be appropriate, but it is not the primary intervention in this situation.

Choice D rationale:

Infection does not explain the sudden decrease in drainage and pink frothy sputum. Although obtaining cultures from the chest tube site is important to assess for infection, it is not the most appropriate intervention at this moment. The priority is to address the potential tension pneumothorax.

Choice B rationale:

The nurse should prioritize monitoring the client's blood glucose levels before administering insulin. It is essential to know the client's current blood sugar level to determine the appropriate dose of insulin to administer safely. Giving insulin without knowing the current blood glucose level can lead to hypoglycemia or hyperglycemia, both of which can be dangerous for the client.

Choice A rationale:

Assessing the client's blood pressure is important but not the priority before administering insulin. High or low blood pressure can be a concern in clients with diabetes, but checking blood glucose levels takes precedence when preparing to administer insulin.

Choice C rationale:

Asking the client about any allergies is a good practice before administering any medication, but it is not the priority in this situation. The immediate concern is to address the hyperglycemia with insulin while ensuring the client's safety.

Choice D rationale:

Checking the client's oxygen saturation is not directly related to insulin administration for diabetes. It may be relevant in certain medical conditions or emergencies, but it is not a priority action before giving insulin.