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.
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Related Questions
Correct Answer is C
Explanation
C. Uric acid is the end product of purine metabolism, and elevated levels of uric acid in the blood can predispose individuals to gout. In acute gout, there is often a marked increase in serum uric acid levels due to the release of uric acid from the breakdown of purines during the inflammatory process.
A. Chloride level is not directly associated with acute gout.
B. Creatinine kinase (CK) is an enzyme found in various tissues, including muscle tissue. Elevated CK levels are associated with muscle damage or injury, such as in cases of muscle trauma, myocardial infarction, or rhabdomyolysis.
D. Intrinsic factor is a glycoprotein produced by the parietal cells of the stomach that is necessary for the absorption of vitamin B12 in the small intestine.
Correct Answer is B
Explanation
B. Sublingual nitroglycerin is intended for the immediate relief of angina symptoms. Clients should take the medication as soon as they experience chest pain or discomfort. Prompt administration can help alleviate symptoms and prevent the progression of angina episodes.
A. If the chest pain persists or worsens after taking the first dose of sublingual nitroglycerin, the client can take a second dose after 5 minutes. However, taking another dose after only 2 minutes may increase the risk of hypotension and other adverse effects.
C. Sublingual nitroglycerin tablets are not meant to be chewed or swallowed. Instead, they should be placed under the tongue and allowed to dissolve completely. Chewing or swallowing the tablet can reduce the medication's effectiveness.

D. Sublingual nitroglycerin should be placed under the tongue, not against the cheek or gum.
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