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 D
Explanation
A) Protective environment
This type of isolation is used for clients with weakened immune systems to protect them from infections. It is not necessary for pertussis, which requires droplet precautions to prevent spread.
B) Airborne precautions
These are used for diseases that are spread through tiny droplets that remain in the air, such as tuberculosis. Pertussis spreads through larger respiratory droplets, not lingering in the air, so airborne precautions are not needed.
C) Contact precautions
These are used for infections spread by direct touch or contact with surfaces. Pertussis primarily spreads through respiratory droplets rather than direct contact, making contact precautions unnecessary.
D) Droplet precautions
Droplet precautions are appropriate for pertussis, as it spreads via respiratory droplets when an infected person coughs or sneezes. This involves wearing masks and maintaining distance to prevent transmission.
Correct Answer is B
Explanation
A. Positive leukocyte esterase is a laboratory finding typically identified during a urinalysis to screen for the presence of white blood cells. While this may indicate a urinary tract infection or renal calculi, it is not a diagnostic marker for an inflamed appendix. In appendicitis, the primary biochemical changes are systemic rather than localized to the urinary excretion system. The nurse would not expect this specific finding to confirm a diagnosis of appendiceal inflammation.
B. Increased pain upon the sudden release of deep abdominal palpation is known as rebound tenderness or Blumberg sign. This clinical phenomenon occurs when the parietal peritoneum is irritated due to the inflammatory process of the adjacent appendix. It is one of the most reliable physical examination findings for identifying peritoneal irritation associated with acute appendicitis. The nurse should expect this reaction during the provider's assessment of the right lower quadrant.
C. A white blood cell (WBC) count of 9,500 mm3 falls within the standard physiological reference range for a healthy adult. In a client with acute appendicitis, the nurse would instead expect to see significant leukocytosis, typically exceeding 10,000 to 18,000 mm3. This elevation in the leukocyte count reflects the body's systemic inflammatory response to the localized infection. A normal count like 9,500 mm3 would be atypical for a client with an actively inflamed appendix.
D. Pain from flexion of the left thigh while lying on the right side is not a characteristic sign of appendicitis. The psoas sign, which is associated with appendicitis, involves pain upon extension or flexion of the right thigh, as the appendix sits in the right iliac fossa. Flexing the left thigh does not cause the anatomical tension required to irritate an inflamed appendix. This finding would suggest a different pathology or involve an unaffected anatomical region.
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