A nurse is assessing a client who is experiencing a hyperglycemic hyperosmolar state. Which of the following findings should the nurse expect? (Select all that apply)
Absence of urine ketones.
Blood glucose 685 mg/dL (74 to 106 mg/dL).
BUN 8 mg/dL (10 to 20 mg/dL).
Fruity breath odor.
Dehydration.
Correct Answer : A,B,E
Choice A reason: Absence of urine ketones is expected in hyperglycemic hyperosmolar state (HHS). Unlike diabetic ketoacidosis (DKA), HHS does not involve significant ketone production because insulin levels are usually sufficient to prevent lipolysis and ketogenesis.
Choice B reason: Blood glucose levels in HHS are extremely elevated, often exceeding 600 mg/dL. A value of 685 mg/dL is consistent with this condition and reflects the severe hyperglycemia that drives osmotic diuresis and dehydration.
Choice C reason: A BUN of 8 mg/dL is within normal range and would not be expected in HHS. Typically, BUN is elevated due to dehydration and reduced renal perfusion. Therefore, this finding is not consistent with HHS.
Choice D reason: Fruity breath odor is characteristic of diabetic ketoacidosis due to acetone accumulation from ketone metabolism. It is not expected in HHS, which lacks significant ketosis.
Choice E reason: Dehydration is a hallmark of HHS. Severe hyperglycemia causes osmotic diuresis, leading to profound fluid loss, hemoconcentration, and electrolyte imbalance.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: Electrical cords secured to the baseboards are safe because they reduce tripping hazards. Loose cords across walkways would be dangerous, but secured cords are appropriate.
Choice B reason: A computer chair with wheels that lock is safe. Locking wheels prevent the chair from rolling unexpectedly, reducing fall risk.
Choice C reason: A standard toilet seat can be a hazard for clients at risk of falls because it is low and requires significant effort to sit and stand. Raised toilet seats or grab bars are recommended to reduce strain and prevent falls. This is the correct hazard identified.
Choice D reason: Carpeted floors in the kitchen are not typically a fall hazard. In fact, carpeting can reduce slipping compared to smooth surfaces. The greater concern in kitchens is wet or greasy floors, not carpeting.
Correct Answer is B
Explanation
Choice A reason: "SQ q AM and q HS" is incorrect because it specifies morning and bedtime administration rather than every 12 hours. This could lead to dosing errors.
Choice B reason: "Enoxaparin 30 mg subcut every 12 hr" is the correct documentation. It uses standard terminology, specifies the correct dose, route, and frequency, and avoids abbreviations that could be misinterpreted.
Choice C reason: "30 mcg" is incorrect because it changes the dosage from milligrams to micrograms, which is a thousand-fold difference. This would result in a dangerous underdose.
Choice D reason: "sub q every AM and HS" is incorrect because it specifies administration twice daily at morning and bedtime rather than strictly every 12 hours. This could cause uneven dosing intervals.
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