A nurse is caring for a patient who has diabetic ketoacidosis (DKA) and hypoxia. Which of the following actions should the nurse take first?
Obtain a prescription for supplemental oxygen.
Obtain a prescription to administer intravenous fluids.
Obtain a prescription to administer insulin.
Obtain a prescription to check the patient's glucose level.
The Correct Answer is A
A. Obtain a prescription for supplemental oxygen. – Correct Answer. Hypoxia must be corrected first to prevent tissue hypoxia and organ failure.
B. Obtain a prescription to administer intravenous fluids. – Incorrect. IV fluids are important but oxygenation is the priority.
C. Obtain a prescription to administer insulin. – Incorrect. Insulin corrects hyperglycemia but is not the first priority over oxygenation.
D. Obtain a prescription to check the patient’s glucose level. – Incorrect. While glucose monitoring is essential, treating hypoxia takes priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Placing a pillow under the patient's head is inappropriate because it may obstruct the airway and does not prevent aspiration.
B. Loosening restrictive clothing can be helpful but is not the priority over airway protection.
C. Clearing the area of hazards is important to prevent injury, but airway protection takes precedence.
D. Positioning the patient in a side-lying position is the priority to maintain airway patency and reduce the risk of aspiration in case of vomiting.
Correct Answer is D
Explanation
A. Bring fresh-cut flowers to cheer the patient up. – Incorrect. Fresh flowers should be avoided due to the risk of fungal or bacterial infections in immunocompromised patients.
B. Take the patient to the cafeteria for meals. – Incorrect. Bone marrow transplant patients are at high risk for infection, and leaving the room increases exposure to pathogens.
C. A cover gown is not necessary when entering the patient’s room. – Incorrect. Depending on the hospital’s isolation precautions, visitors may be required to wear gowns and masks to protect the patient.
D. Do not visit if you have had a recent infection. – Correct Answer. Even mild infections can be life-threatening to patients undergoing a bone marrow transplant, so visitors should stay away if they are unwell.
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