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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. Correct. A platelet count <20,000/μL increases bleeding risk. Checking for occult blood helps detect hidden gastrointestinal bleeding.

B. Incorrect. Hydration is important but does not directly address thrombocytopenia management.

C. Incorrect. While oral hygiene is important, frequent brushing could cause bleeding with low platelets.

D. Incorrect. Monitoring temperature is important for infection risk but does not address bleeding concerns.

A. Check the patient's blood temperature. B. Administer an oral analgesic. C. Perform a complete blood count. D. Evaluate the patient's neurological status.

Correct Answer is A

Explanation

A. Check the patient’s blood temperature. – Correct Answer. A headache and stiff neck are classic signs of meningitis. Fever is another key symptom, so checking temperature helps confirm suspicion and guides urgent intervention.

B. Administer an oral analgesic. – Incorrect. Pain management is secondary. The priority is assessing for infection (meningitis).

C. Perform a complete blood count. – Incorrect. While a CBC may show elevated WBCs, immediate assessment is more urgent.

D. Evaluate the patient’s neurological status. – Incorrect. While neurological assessment is important, confirming fever as an infection indicator is the first step.

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