A family member brings a client with type 1 diabetes mellitus to the emergency department. The client is confused, has a heart rate of 100, respirations of 9, and a fruity smell to the breath. The initial action the nurse should take is to:
1. Notify the physician.
2. Call for the code team.
3. Assess the blood sugar.
4. Measure urine output.
3. Assess the blood sugar.
Rationale:
The client is showing signs of the beginning of a diabetic coma. The first step by the nurse would be to assess the client's blood sugar. The nurse would then notify the physician of the results. A code team is not necessary as the client is breathing and has a heart rate. Measuring urine output would be a component of an ongoing assessment.
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