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Zorluk: OrtaPhysiological Adaptation

A triage nurse evaluates a client with type 1 diabetes mellitus who presents with a capillary blood glucose of 610 mg/dL, fruity breath odor, and profound lethargy. The client is exhibiting deep, rapid respirations. Arrange the following nursing interventions in the correct chronological order of execution.

  1. 1Assess the client's airway patency and oxygen saturation.
  2. 2Establish large-bore intravenous (IV) access.
  3. 3Administer a rapid bolus of 0.9% sodium chloride.
  4. 4Review the initial serum potassium laboratory level.
  5. 5Initiate a continuous intravenous infusion of regular insulin.

Cevap

The correct priority sequence is: 1) Assess airway patency, 2) Establish large-bore IV access, 3) Administer a bolus of 0.9% sodium chloride, 4) Review the serum potassium level, and 5) Initiate a continuous infusion of regular insulin.
The management of an acute physiological crisis like Diabetic Ketoacidosis strictly follows the ABCs (Airway, Breathing, Circulation) and specific metabolic safety guidelines. Airway is always verified first. Circulation is addressed next by securing IV access and administering isotonic fluids to resolve life-threatening hypovolemia. Finally, before the metabolic issue (hyperglycemia) can be treated with insulin, the nurse must ensure the serum potassium level is known, as insulin profoundly lowers serum potassium.

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1
Perform an airway and respiratory assessment.
Ensures adequate oxygenation and ventilation.
Following the ABCs (Airway, Breathing, Circulation), confirming airway patency is always the absolute first priority, particularly given the client's lethargy and abnormal breathing pattern.
2
Insert a large-bore IV catheter.
Provides a reliable route for rapid fluid administration.
Vascular access is a mechanical necessity before any pharmacological or fluid resuscitation can begin for a physiologically unstable client.
3
Infuse 0.9% sodium chloride rapidly.
Expands intravascular volume and improves tissue perfusion.
Clients with Diabetic Ketoacidosis (DKA) experience severe osmotic diuresis. Addressing the resulting hypovolemia takes precedence over correcting the blood glucose level.
4
Check the baseline serum potassium level.
Identifies current electrolyte status to prevent iatrogenic harm.
Insulin administration drives potassium back into the cells. If a client is already hypokalemic, giving insulin first can induce fatal cardiac arrhythmias.
5
Start an IV regular insulin infusion.
Drives glucose into cells and stops ketone production.
Once intravascular volume is being restored and potassium is confirmed safe, insulin is safely administered to resolve the underlying hyperglycemia and acidosis.

Anahtar Kavram

Prioritization of acute interventions in Diabetic Ketoacidosis (DKA) based on ABCs and physiological safety.
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Konular

Physiological Adaptation

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