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.
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Related Questions
Correct Answer is D
Explanation
A. Eat plenty of fresh fruits and vegetables. – Incorrect. Raw fruits and vegetables can harbor bacteria, increasing the risk of infection for a patient with neutropenia.
B. Take temperature weekly. – Incorrect. Patients with neutropenia should check their temperature daily, as fever may be the first sign of infection.
C. Perform mild exercise, such as gardening. – Incorrect. Gardening exposes the patient to soilborne fungi and bacteria, which can be harmful.
D. Avoid crowds. – Correct Answer. Neutropenic patients are highly susceptible to infections, so avoiding crowds helps reduce the risk of exposure to contagious illnesses.
Correct Answer is B
Explanation
A. Tachycardia does not occur with autonomic dysreflexia.
B. Autonomic dysreflexia is a life-threatening condition caused by a noxious stimulus (e.g., full bladder, constipation) in patients with spinal cord injuries above T6. It leads to severe hypertension and reflex bradycardia.
C. Hypotension is not a symptom; autonomic dysreflexia causes hypertension.
D. Tachycardia and hypotension are more associated with spinal shock rather than autonomic dysreflexia.
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