A nurse is caring for a patient with diabetic ketoacidosis and hypoxia.
What is the first action the nurse should take?

Choice A rationale:

Reflex incontinence is a type of urinary incontinence that occurs when the person has no control over urination. They’re unable to feel when their bladder is full and can’t control the process of emptying it. This is often due to a brain or spinal cord injury that disrupts communication between these organs. However, this condition does not necessarily indicate the need for catheterization in a client with paraplegia who is already on an intermittent urinary catheterization program.

Choice B rationale:

Urge incontinence, also known as overactive bladder, is characterized by a sudden, intense urge to urinate, followed by an involuntary loss of urine. This condition can be caused by various factors, including neurological disorders, bladder abnormalities, and certain medications. While it can be a challenge for individuals with paraplegia, it does not directly indicate the need for catheterization.

Choice C rationale:

Nocturnal enuresis, or bedwetting, is involuntary urination while asleep. It’s a common condition, especially in young children, but it can affect individuals of any age. In the context of a client with paraplegia, nocturnal enuresis could be a symptom of a larger issue, such as a urinary tract infection or bladder dysfunction, but it does not directly indicate the need for catheterization.

Choice D rationale:

Suprapubic discomfort or pain in the area above the pubic bone could be a sign of bladder distension, which is a common complication in individuals with spinal cord injuries. Bladder distension can occur when the bladder becomes overly full and can’t empty, causing discomfort or pain in the lower abdomen. This is a clear indication for the need to catheterize the client.

Choice A rationale:

Tachycardia, or a rapid heart rate, is not typically an adverse effect of oxygen therapy. Oxygen therapy is often used to help people with conditions like COPD, COVID-19, emphysema, and sleep apnea get enough oxygen to function and stay well. While tachycardia can be a symptom of these conditions, it is not directly caused by the oxygen therapy itself.

Choice B rationale:

Cracks in the oral mucous membranes can indeed be an adverse effect of oxygen therapy. Oxygen therapy involves the delivery of highly concentrated oxygen, which can cause irritation and dryness in the airways, including the oral mucous membranes. This can lead to cracks and discomfort in the mouth. Therefore, it’s important for healthcare providers to monitor patients receiving oxygen therapy for signs of this adverse effect.

Excessive pulmonary secretions are not typically a direct adverse effect of oxygen therapy. While conditions that often require oxygen therapy, such as pneumonia and COPD, can lead to increased pulmonary secretions, these are symptoms of the underlying disease rather than the oxygen therapy itself.

Choice D rationale:

Poor skin turgor is not typically an adverse effect of oxygen therapy. Skin turgor refers to the elasticity of the skin, and poor skin turgor is often a sign of dehydration. While oxygen therapy can cause dryness of the mucous membranes, it does not typically affect the hydration status of the skin.