A nurse is caring for a patient with diabetic ketoacidosis and hypoxia.
What is the first action the nurse should take?
Obtain a prescription to administer insulin.
Obtain a prescription for supplemental oxygen.
Obtain a prescription to check the patient’s glucose level.
Obtain a prescription to administer intravenous fluids.
The Correct Answer is B
Choice A rationale:
Administering insulin is a crucial step in managing diabetic ketoacidosis (DKA), as insulin deficiency is a primary cause of DKA12. However, it is not the first action to take when a patient presents with both DKA and hypoxia. While insulin helps to reduce blood glucose levels and suppress the production of ketones, it does not address the immediate life-threatening condition of hypoxia.
Choice B rationale:
Hypoxia, or low levels of oxygen in the body, is a medical emergency that requires immediate attention. Supplemental oxygen can help increase the oxygen levels in the patient’s blood, thereby alleviating hypoxia. In the context of a patient with DKA and hypoxia, providing supplemental oxygen would be the first action to take to stabilize the patient’s condition before addressing the DKA12.
Choice C rationale:
Checking the patient’s glucose level is an important part of managing DKA, as hyperglycemia is a key feature of this condition. However, it is not the first action to take in this scenario. While monitoring glucose levels can guide the administration of insulin and other treatments for DKA, it does not address the immediate threat posed by hypoxia.
Choice D rationale:
Administering intravenous fluids is another important step in managing DKA12. Dehydration is a common complication of DKA due to excessive urination caused by high blood sugar levels. However, similar to Choices A and C, while it is an important part of treatment, it is not the first action to take when a patient presents with both DKA and hypoxia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Muscle twitching is a symptom of oxygen toxicity. Oxygen toxicity is a condition resulting from the harmful effects of breathing molecular oxygen (O2) at increased partial pressures. Severe cases can result in cell damage and death, with effects most often seen in the central nervous system, lungs, and eyes. Central nervous system symptoms can include muscle twitching.
Choice B rationale:
Redness of the face is not typically associated with oxygen toxicity. Oxygen toxicity primarily affects the central nervous system, lungs, and eyes. It does not typically cause redness of the face.
Choice C rationale:
Swelling around the eyes is not a common symptom of oxygen toxicity. The primary effects of oxygen toxicity are seen in the central nervous system, lungs, and eyes. However, this does not typically manifest as swelling around the eyes.
Choice D rationale:
A metallic taste in the mouth is not a known symptom of oxygen toxicity. Oxygen toxicity is a condition that results from the harmful effects of breathing molecular oxygen (O2) at increased partial pressures. It primarily affects the central nervous system, lungs, and eyes, but a metallic taste in the mouth is not a recognized symptom.
Correct Answer is C
Explanation
Choice A rationale:
Hypothermia, or abnormally low body temperature, is not typically a symptom of diarrhea. While it’s possible for a person with severe diarrhea to experience chills or feel cold, hypothermia is not a direct result of diarrhea.
Choice B rationale:
A rigid abdomen is often a sign of a serious condition like peritonitis (inflammation of the peritoneum, the tissue that lines the inner wall of the abdomen), but it is not typically associated with diarrhea.
Choice C rationale:
Dehydration is a common complication of diarrhea. When a person has diarrhea, they can lose a lot of fluid and electrolytes quickly, leading to dehydration. Symptoms of dehydration can include thirst, less frequent urination, dark-colored urine, fatigue, dizziness, and confusion.
Choice D rationale:
Decreased bowel sounds are not typically associated with diarrhea. In fact, bowel sounds may actually increase in some cases of diarrhea due to increased gut motility.
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