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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E","J"]
Explanation
The client is having typical signs and symptoms of acute coronary syndrome - pain radiating to the left arm, nausea, diaphoresis, shortness of breath and tachycardia
Her diet history - daily bacon and eggs increases her cardiovascular risk
Her cool skin and weak peripheral pulses is an indication of poor perfusion due to impaired myocardial contractility due to myocardial infarction.
Correct Answer is A
Explanation
A. Joint inflammation(arthritis) is a common manifestation of systemic lupus erythematosus. SLE can cause inflammation in the joints, leading to symptoms such as pain, swelling, stiffness, and decreased range of motion. It often affects the small joints of the hands, wrists, and knees.
B. Tophi are deposits of uric acid crystals that form under the skin in people with chronic gout.
C. Esophagitis, or inflammation of the esophagus, can occur in systemic lupus erythematosus as part of gastrointestinal involvement. However, it is not one of the most common manifestations of SLE.
D. "Bull's eye" lesion, also known as erythema multiforme, is a skin manifestation seen in conditions such as Lyme disease and certain drug reactions. It is not typically associated with systemic lupus erythematosus.
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