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 D

Explanation

D. Diet plays a crucial role in managing ulcerative colitis symptoms. Certain foods may trigger flare-ups, while others may be better tolerated. A dietitian can provide personalized dietary advice to help manage symptoms, ensure adequate nutrition, and optimize overall health.
A. Ulcerative colitis is a chronic inflammatory bowel disease that primarily affects the colon and rectum. While pain management is crucial, it is not a priority at this point.
B. Hospice services are generally provided to individuals who have a terminal illness and are nearing the end of life. While ulcerative colitis can be a serious condition, it is not typically considered a terminal illness in itself.
C. A wound, ostomy, and continence nurse (WOCN) specializes in the care of patients with ostomies (such as those resulting from surgery for ulcerative colitis), wounds, and continence issues. The client does not require the services at this point as the decision for the surgery has not been made.

A. Monitor the client's temperature once every 6 hr. B. Make sure the client's room has positive-pressure airflow. C. Wear an N95 respirator when providing direct client care. D. Make sure dietary plates and utensils are disposable.

Correct Answer is C

Explanation

A. Monitoring of vital signs should be more frequent

B. This is an important infection control measure for immunocompromised clients. However, this is more about environmental control and may not directly address the specific isolation protocols regarding direct person-to-person transmission.
C. Wearing an N95 respirator may be recommended for direct care, especially if there is concern about exposure to airborne infections from the environment, staff, or visitors.
D. While disposable plates and utensils are generally preferred for infection control, this is not a specific intervention for protective isolation.

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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

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