A nurse in an emergency department is caring for a client whose blood glucose level indicates diabetic ketoacidosis. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Explanation & Rationale
A. Monitor for pulmonary edema: Monitoring for pulmonary edema is important during fluid replacement to detect complications from rapid IV infusion. However, it is performed after initial stabilization, fluid administration, and ongoing assessment rather than as the first step. B. Administer prescribed IV fluids: IV fluid administration is critical for correcting dehydration and restoring perfusion in DKA. This step follows the initial assessment of airway and vital signs to ensure safe and effective fluid resuscitation. C. Assess vital signs to determine hydration status: Assessing vital signs helps identify the degree of hypovolemia and guides the rate and type of fluid replacement. This assessment occurs immediately after ensuring the airway is patent and the client is responsive. D. Check the client's airway and level of consciousness: The first priority in DKA is to ensure airway patency and evaluate neurological status. Changes in consciousness may indicate severe hyperglycemia, electrolyte imbalance, or hypoperfusion, and addressing airway concerns takes precedence before other interventions.