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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

    A. Check the client's airway and level of consciousness: This is the first priority. In diabetic ketoacidosis (DKA), electrolyte imbalances and severe hyperglycemia can cause altered mental status. Ensuring airway patency and neurological stability is critical according to the ABC framework. B. Monitor for pulmonary edema: This is performed after initiating fluid therapy. Rapid fluid administration, especially in clients with compromised cardiac function, can lead to pulmonary edema. Continuous monitoring ensures early detection and intervention. C. Administer prescribed IV fluids: Fluid replacement is essential to restore intravascular volume, correct dehydration, and improve tissue perfusion. It also helps lower glucose levels and facilitates electrolyte replacement. D. Assess vital signs to determine hydration status: After airway and neurological status are evaluated, the nurse assesses vital signs and hydration to identify hypovolemia, hypotension, or tachycardia, which are common in DKA due to osmotic diuresis.

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