A nurse is caring for a female client who had a stroke. Which of the following findings should indicate to the nurse that the client has an increased risk of developing skin breakdown?

Hgb 18 g/dL (12 to 16 g/dl)

WBC 12.000/mm3 (5,000 to 10,000/mm3)

25-Hydroxyvitamin D 92 ng/ml. (25 to 80 ng/mL)

Albumin 3.1 g/dL (3.5 to 5 g/dL)

Answer and Explanation

The Correct Answer is D

Albumin is a protein that plays a crucial role in maintaining skin health. Low albumin levels (hypoalbuminemia) can lead to poor wound healing and skin vulnerability.

Hemoglobin level, white cell count and 25-hydroxyvitamin have no direct role in skin breakdown.

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Correct Answer is B

Explanation

The transverse colon is located across the right upper quadrant, epigastrium and the left upper quadrant.

A. Initiate IV fluid replacement. B. Measure the client's urinary output. C. Administer insulin. D. Teach the client about manifestations of HHS

Correct Answer is A

Explanation

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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A nurse is caring for a female client who had a stroke. Which of the following findings should indicate to the nurse that the client has an increased risk of developing skin breakdown?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

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?

Correct Answer is A

Explanation

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