A nurse is caring for a client who has a new onset of hyperglycemic hyperosmolar state (HHS). Which of the following interventions by the nurse is the highest priority?

Initiate IV fluid replacement.

Measure the client's urinary output.

Administer insulin.

Teach the client about manifestations of HHS

Answer and Explanation

The Correct Answer is A

A.   Initiate IV fluid replacement is the highest priority intervention. HHS is characterized by severe dehydration due to osmotic diuresis resulting from hyperglycemia. IV fluid replacement is essential to correct dehydration and restore intravascular volume, which can help improve tissue perfusion and prevent further complications.
B.   Monitoring urinary output is important in assessing renal function and response to fluid replacement therapy. However, it is not the highest priority intervention.
C.   While insulin therapy is an essential part of managing hyperglycemia in HHS, it is not the highest priority intervention at the immediate onset of HHS.

D.   Patient education about the manifestations and management of HHS is important for long-term management and prevention of recurrence. However, it is not the highest priority when the client is experiencing an acute episode of HHS.

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Correct Answer is ["A","B","D","E"]

Explanation

Chest pain radiating to the left arm is characteristic for angina in coronary artery disease. This is suggested more by the client’s medical history of hypertension, hyperlipidemia and type 2 diabetes mellitus.

Clients with angina are scheduled for diagnostic cardiac catheterization to assess the extent of coronary blockage

Heparin is used to prevent the propagation of a clot that is formed on an unstable atherosclerotic plaque. Beta blockers are prescribed to lower the heart rate. This reduces the myocardial demand for oxygen.

The firstline medication include antiplatelets unless there's concurrent venous thromboembolism.

Keeping the client NPO within 2 hours of the procedure is important to prevent aspiration whole under sedation.

Ambulation increases demand on the heart which may worsen the pain Antibiotics have no role in coronary artery disease.

A. Respiratory rate of 16/min B. Decrease in blood pressure C. Increase in urinary output D. Blood glucose of 110 mg/dL

Correct Answer is B

Explanation

Telmisartan is an angiotensin II receptor blocker (ARB) used to treat hypertension by lowering blood pressure. Therefore, a decrease in blood pressure would suggest that the medication is working as intended.

Telmisartan has no effect on respiratory rate, urine output or blood glucose.

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A nurse is caring for a client who has a new onset of hyperglycemic hyperosmolar state (HHS). Which of the following interventions by the nurse is the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the client's diagnostic results and vital signs. Exhibits Which of the following actions should the nurse take? Select all that apply.

Correct Answer is ["A","B","D","E"]

Explanation

A nurse is assessing a client who is taking telmisartan. The nurse should identify that which of the following findings indicates that the medication has been effective?

Correct Answer is B

Explanation

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