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 B

Explanation

B. Proteinuria is a hallmark finding in nephrotic syndrome. Proteinuria refers to the presence of excess protein, particularly albumin, in the urine. It occurs due to increased permeability of the glomerular filtration barrier, allowing proteins to leak into the urine rather than being retained in the bloodstream.
A. Individuals with nephrotic syndrome may be at an increased risk of thrombosis (formation of blood clots) due to loss of anticoagulant proteins such as antithrombin III in the urine.
C. Nephrotic syndrome is characterized by hypoalbuminemia, which is a decreased level of albumin in the bloodstream. The loss of albumin in the urine leads to decreased serum albumin levels, contributing to edema formation and other complications associated with nephrotic syndrome.

D. Decreased serum lipid levels is not a typical finding in nephrotic syndrome. In fact, individuals with nephrotic syndrome often have dyslipidemia, characterized by elevated serum lipid levels, including cholesterol and triglycerides.

A. Monitor vital signs at least every 4 hr. B. Insert an indwelling urinary catheter. C. Change the client's linens three times a day. D. Place the client in a room with negative airflow.

Correct Answer is A

Explanation

A. Frequent vitals monitoring to allow for early detection of infection. Clients with neutropenia are at increased risk of infections.
B. Indwelling catheter and other devices should be avoided in individuals with neutropenia die to risk of sepsis.
C. Changing the client’s linen is important. However, doing it 3 times a day is not necessary.
D. Clients should be placed in a positive airflow room to prevent contracting infections from infected persons

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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

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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