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    Ati rn adult medical surgical 2023 proctored exam

    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

    Rationale: A. Check the client's airway and level of consciousness: The first priority is to assess the client's airway and level of consciousness to ensure that they are breathing properly and to gauge the severity of the condition. B. Assess vital signs to determine hydration status: After assessing the airway and consciousness, it’s crucial to evaluate vital signs to determine the client's hydration status, as dehydration is a significant concern in diabetic ketoacidosis. C. Administer prescribed IV fluids: IV fluids should be administered promptly to treat dehydration, restore electrolyte balance, and help improve circulation. This is typically the next step after assessing vital signs and hydration status. D. Monitor for pulmonary edema: Once the IV fluids are being administered, the nurse should monitor for potential complications, such as pulmonary edema, which can occur due to fluid overload or other factors related to treatment.

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