A nurse in an emergency department is caring for an older adult client who has diabetes mellitus and is in a hyperglycemic-hyperosmolar state. Which of the following actions should the nurse take first?
Evaluate the client's understanding of diabetes management.
Administer potassium supplements.
Initiate a continuous infusion of 0.9% sodium chloride.
Chek for improvements in the client's level of consciousness.
The Correct Answer is C
A) Evaluate the client's understanding of diabetes management: While it is important to assess the client’s understanding of diabetes management to prevent future hyperglycemic episodes, this is not the immediate priority. The client's current hyperglycemic-hyperosmolar state needs urgent intervention to stabilize their condition before educational measures can be effective.
B) Administer potassium supplements: Potassium supplementation may be necessary, especially if the client is hypokalemic, but it is not the first action. Electrolyte levels should be monitored and corrected as part of the treatment, but the initial priority is to address the severe dehydration and hyperglycemia.
C) Initiate a continuous infusion of 0.9% sodium chloride: This is the most critical first step. Clients in a hyperglycemic-hyperosmolar state are typically severely dehydrated due to osmotic diuresis. Initiating a continuous infusion of isotonic saline helps to restore intravascular volume, improve perfusion, and stabilize hemodynamics, which is essential before addressing other issues.
D) Check for improvements in the client's level of consciousness: Monitoring the client's level of consciousness is important as it provides information about their neurological status and response to treatment. However, this is a subsequent action after initiating fluid resuscitation, which directly addresses the immediate life-threatening aspects of the hyperglycemic-hyperosmolar state.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Orthostatic hypotension:
Tamsulosin, an alpha-blocker used to treat benign prostatic hypertrophy, can cause orthostatic hypotension, which is a significant adverse effect. This condition involves a sudden drop in blood pressure when standing up, leading to dizziness or fainting. It's important for clients to report these symptoms to their healthcare provider for potential adjustment of medication or additional instructions on managing this side effect.
B) Muscle tenderness:
Muscle tenderness is not commonly associated with tamsulosin. While muscle pain can occur with other medications, it is not a known adverse effect of tamsulosin and does not require immediate notification to the provider in the context of this medication.
C) Decreased heart rate:
Tamsulosin does not typically cause bradycardia (decreased heart rate). This side effect is more associated with beta-blockers or other cardiac medications, rather than alpha-blockers like tamsulosin. Reporting this would be relevant for those other medications but not for tamsulosin.
D) Oliguria:
Oliguria, or decreased urine output, is not a known adverse effect of tamsulosin. Tamsulosin helps improve urine flow in clients with benign prostatic hypertrophy, so reporting oliguria would not be pertinent in this context. Instead, it could indicate another underlying issue.
Correct Answer is B
Explanation
A) Provide a detailed account of the feelings and sounds the client will experience:
While explaining the procedure can be helpful, it might increase anxiety for someone with claustrophobia by focusing on potentially distressing details. It's more effective to use relaxation techniques or medications to manage acute anxiety.
B) Obtain a prescription for clonazepam:
Clonazepam, a benzodiazepine, can help reduce anxiety and is often used to manage claustrophobia during procedures like an MRI. This medication can help the client stay calm and more comfortable during the scan.
C) Obtain a prescription for ziprasidone:
Ziprasidone is an antipsychotic medication and is not typically used for managing situational anxiety or claustrophobia. Using an appropriate anxiolytic like clonazepam is more effective in this context.
D) Inform the client that the time spent in the MRI machine will only be 5 min:
This statement is misleading as MRI scans usually take longer than 5 minutes. Providing inaccurate information can undermine trust and increase anxiety if the procedure takes longer than stated.
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