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 B
Explanation
Choice A rationale: Cloudy efluent doesn't necessarily indicate a need for emergency surgery unless accompanied by severe symptoms.
Choice B rationale: Cloudy efluent may indicate infection, so obtaining a culture and sensitivity test is crucial for appropriate treatment.
Choice C rationale: This step might be necessary if the efluent suggests infection, but sending a specimen for testing is the immediate priority.
Choice D rationale: This action isn't the first step; investigating the cause of cloudiness through testing is essential.
Correct Answer is C
Explanation
Choice A rationale: Performing active range of motion exercises may not be safe or appropriate immediately following a hemorrhagic stroke.
Choice B rationale: Maintaining the head of bed flat or at a 30-degree position might be used for ischemic strokes but not necessarily for hemorrhagic strokes.
Choice C rationale: Teaching measures to avoid the Valsalva maneuver (straining during activities like defecation) helps prevent sudden increases in intracranial pressure, which can be detrimental after a hemorrhagic stroke.
Choice D rationale: Monitoring for Battle's sign (bruising behind the ears associated with basilar skull fracture) is not relevant in the care of a hemorrhagic stroke.
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