The patient admitted with diabetic ketoacidosis has rapid, deep respirations. What action should the nurse take?

Correct Answer: C

Rationale: The correct answer is C, administer the prescribed normal saline bolus and insulin. In diabetic ketoacidosis, rapid, deep respirations, known as Kussmaul breathing, occur due to compensatory mechanisms to lower blood pH. Normal saline bolus helps correct dehydration and insulin therapy helps lower blood sugar levels, leading to improved acidosis. Option A is incorrect as lorazepam does not address the underlying cause of the rapid respirations. Option B is incorrect as oxygen is not the priority in this situation. Option D is incorrect as guided imagery does not address the physiological needs of the patient in this critical condition.

Correct Answer: C

Rationale: The correct answer is C: Avoid exposing the treated area to sunlight. This is important because radiation therapy can make the skin more sensitive to sunlight, leading to increased risk of sunburn and skin damage. Sun exposure can worsen skin reactions and delay healing. Choice A is incorrect because heat sources like heating pads can exacerbate skin irritation. Choice B is incorrect as alcohol-based lotions can further irritate the skin. Choice D is incorrect as hot water and strong soap can be too harsh on the sensitive skin. Overall, protecting the treated area from sunlight is crucial for optimal skin care during radiation therapy.

Correct Answer: A

Rationale: The correct answer is A: Administer regular insulin intravenously. In DKA, the priority is to lower blood glucose levels and correct acidosis. Regular insulin intravenously is the fastest way to reduce blood glucose levels. Oral hypoglycemic agents (B) are not effective in DKA. Sodium bicarbonate (C) is not routinely recommended in DKA as it may worsen acidosis. Providing a high-calorie diet (D) is not appropriate as the focus should be on treating the underlying condition first.

Correct Answer: B

Rationale: The correct answer is B: Avoid intramuscular injections. Thrombocytopenia is a condition characterized by low platelet count, which can lead to impaired blood clotting. Intramuscular injections can cause bleeding and bruising due to the decreased ability of blood to clot. Therefore, it is crucial to avoid invasive procedures like intramuscular injections to prevent excessive bleeding in patients with thrombocytopenia. Encouraging light exercise (choice A) can be beneficial for overall health but may not directly address the risk of bleeding. Avoiding aspirin (choice C) is important as it can further increase the risk of bleeding. Using a soft toothbrush for oral care (choice D) is a good practice, but it does not directly address the risk associated with intramuscular injections in patients with thrombocytopenia.

Correct Answer: C

Rationale: The correct answer is C: High Fowler's. This position helps improve lung expansion and breathing efficiency by maximizing chest expansion. Sitting upright reduces pressure on the diaphragm, allowing for better ventilation. Supine (A) position can worsen dyspnea by restricting lung expansion. Prone (B) position is not ideal for COPD patients as it can hinder breathing. Trendelenburg (D) position, where the patient's feet are elevated above the head, can increase pressure on the diaphragm and impair breathing, making it inappropriate for a patient experiencing severe dyspnea.