A 65-year-old patient with type 2 diabetes has a urinary tract infection (UTI). The unlicensed assistive personnel (UAP) reported to the nurse that the patient's blood glucose is 642 mg/dL and the patient is hard to arouse. When the nurse assesses the urine, there are no ketones present.
What collaborative care should the nurse expect for this patient?
Administer IV fluids rapidly to correct dehydration.
Routine insulin therapy and exercise
Cardiac monitoring to detect potassium changes
Administer a different antibiotic for the UTI.
The Correct Answer is A
Choice A rationale: This patient is likely experiencing hyperosmolar hyperglycemic state (HHS). Rapid administration of IV fluids is crucial to correct severe dehydration associated with HHS.
Choice B rationale: Routine insulin therapy and exercise might be components of diabetes management but wouldn't directly address the immediate concern of severe dehydration and high blood glucose.
Choice C rationale: Cardiac monitoring for potassium changes might be necessary but isn't the primary immediate intervention for HHS.
Choice D rationale: Administering a different antibiotic for the UTI is incorrect, because there is no evidence that the current antibiotic is ineffective or causing adverse effects. The UTI may have triggered the HHS, but it is not the main problem that needs to be addressed urgently.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: A breast lump that increases in size before the menstrual period might be related to hormonal changes and is not necessarily indicative of a concerning issue.
Choice B rationale: Bilateral breast nodules that are tender with palpation might be related to benign conditions or hormonal changes.
Choice C rationale: A small, mobile, rubbery breast lump could suggest a benign condition like a fibroadenoma, which might not be as concerning.
Choice D rationale: A breast nodule that is 1 cm in size, nontender, and fixed could potentially raise concerns about malignancy and requires further evaluation.
Correct Answer is C
Explanation
Choice A rationale: A client with nausea, vomiting, and abdominal pain may have gastroenteritis, food poisoning, or appendicitis, which are not directly related to the eyes.
Choice B rationale: A client with chest tightness and heartburn may have gastroesophageal reflux disease (GERD), angina, or myocardial infarction (MI), which are also not associated with the eyes.
Choice C rationale: A client with facial drooping and left-sided weakness may have a stroke, which is a medical emergency that requires immediate attention. An eye examination can help detect signs of stroke, such as pupil asymmetry, visual field defects, or eye movement abnormalities. A stroke can cause permanent brain damage or death if not treated promptly.
Choice D rationale: A client with fatigue, fever, and productive cough may have a respiratory infection, such as pneumonia or tuberculosis, which are unlikely to affect the eyes unless there is a systemic complication.
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