The practical nurse (PN) is assigned to care for a client who underwent fixation of a mandible fracture. Upon entering the client's room, the PN should confirm the presence of which item(s) in the client's room? Select all that apply.

Choice A reason: Assessing urine for ketones is an important step in diagnosing diabetic ketoacidosis (DKA), a serious complication of diabetes. Ketones are produced when the body breaks down fat for energy due to a lack of insulin. High levels of ketones in the urine can indicate DKA. However, while this is a necessary assessment, it is not the immediate priority. The most urgent action is to measure the blood glucose to determine if hyperglycemia is present, which is a key indicator of DKA.
Choice B reason: Auscultating breath sounds is an important assessment to evaluate the client's respiratory status. Deep, rapid respirations (Kussmaul respirations) are often associated with DKA as the body attempts to compensate for metabolic acidosis. While auscultating breath sounds is valuable, it is not the first action to take. The primary concern is to confirm hyperglycemia, which is a critical step in diagnosing and managing DKA.
Choice C reason: Elevating the head of the bed can help improve the client's comfort and respiratory function, especially if they are experiencing difficulty breathing. However, this action does not directly address the underlying issue of hyperglycemia and potential DKA. While it can be part of supportive care, the immediate priority is to measure the blood glucose levels to assess the severity of the condition and initiate appropriate treatment.
Choice D reason: Measuring the blood glucose is the most critical and immediate action. Deep, rapid respirations and a fruity breath odor are classic signs of DKA, a life-threatening condition that requires prompt diagnosis and treatment. By measuring the blood glucose, the practical nurse can confirm hyperglycemia and initiate interventions to manage blood sugar levels, such as insulin administration and fluid replacement. Early detection and treatment are essential to prevent complications and stabilize the client’s condition.

Choice A rationale: Large amounts of water-based lubricant can interfere with the cell sample and lead to inaccurate results. Providers usually use warm water or a very small amount of lubricant.

Choice B rationale: A specimen bottle or liquid-based cytology vial is required to transport the cervical cells to the laboratory for analysis. This ensures the cells remain preserved during transit.

Choice C rationale: If the traditional method is used, the provider needs a microscopic slide to smear the cells and a fixative spray to prevent the cells from air-drying and distorting.

Choice D rationale: A disposable vaginal speculum is essential to visualize the cervix. It holds the vaginal walls apart so the provider can identify the cervical os for sampling.

Choice E rationale: A cytobrush or plastic spatula is the specific device used to scrape the ectocervix and collect endocervical cells. These tools ensure an adequate sample of the transformation zone.