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
A. Bladder spasms are a common postoperative complication after TURP, and they are typically associated with the irritation of the bladder wall. Cold compresses may be helpful for reducing muscle spasms or swelling in other situations, but they are not typically effective for relieving bladder spasms specifically.
B. Securing the urinary catheter is important to prevent dislodgement and ensure proper drainage. However, securing it to the upper left quadrant of the abdomen is not a standard practice.
C. The appropriate response is often to irrigate the catheter to relieve the obstruction and restore normal flow. While 0.9% sodium chloride (normal saline) is typically used for irrigation, the term "intermittent" refers to manually irrigating the catheter at intervals to flush out any blockages, which is an appropriate approach when there is a concern about obstruction.
D. Encouraging the client to urinate every 2 hours is not feasible or necessary in this situation.
Correct Answer is D
Explanation
D. Propofol is an emulsion formulation that contains egg lecithin as an ingredient. Therefore, individuals with an egg allergy may be at risk for allergic reactions to propofol. It is essential for the nurse to identify any egg allergies in preoperative clients to prevent potential adverse reactions to propofol.
A. Propofol is not derived from strawberries, and there is no cross-reactivity between propofol and strawberries.
B. While shellfish allergies are common, there is no known cross-reactivity between shellfish and propofol.
C. Avocado allergy is not associated with potential reactions to propofol.
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