A patient with Type 2 diabetes is brought into the emergency room in an unresponsive state.
Vital signs include BP: 88/56, HR: 122, RR 16, Sp 95% and glucose of 720 mg/dL. A diagnosis of Hyperosmolar Hyperglycemic Syndrome (HHS) is made.The nurse prepares for the administration of which priority therapy?

Administration of Glucagon.

Dextrose 50%.

0.45% Normal Saline IV.

0.9% saline solution IV.

Answer and Explanation

The Correct Answer is D

Choice D rationale

Hyperosmolar Hyperglycemic Syndrome (HHS) is a serious complication of diabetes that occurs when blood sugar levels are extremely high. The primary treatment for HHS is intravenous fluids and insulin. Specifically, 0.9% saline solution IV is often used initially to restore volume and correct severe dehydration.

Choice A rationale

Administration of Glucagon is not the primary treatment for HHS. Glucagon is a hormone that raises blood glucose levels and would not be beneficial in a situation where blood glucose is already extremely high.

Choice B rationale

Dextrose 50% is a concentrated glucose solution and would not be appropriate in the treatment of HHS, where blood glucose levels are already dangerously high.

Choice C rationale

While IV fluids are a crucial part of the treatment for HHS, 0.45% Normal Saline (also known as half-normal saline) is a hypotonic solution and is not typically the first choice for fluid resuscitation in HHS. The preferred initial fluid is often 0.9% saline (normal saline), which is isotonic.

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Correct Answer is C

Explanation

Choice A rationale

Monitoring the peak level of the antibiotic is important, but it is not the priority nursing action. Peak levels are typically drawn after the drug has been administered and are used to assess whether the dosage is sufficient.

Choice B rationale

Assessing the client’s vital signs is an important part of nursing care, but it is not the priority action when preparing to administer an aminoglycoside antibiotic.

Choice C rationale

Obtaining a serum trough level is the priority nursing action. Trough levels are drawn just before the next dose of the drug is due and are used to assess whether the dosage is safe.

Choice D rationale

Asking the client about drug allergies is an important part of nursing care, but it is not the priority action when preparing to administer an aminoglycoside antibiotic.

A. The recommended diabetic diet. B. Administration of insulin. C. Importance of exercise. D. Urine testing for ketones.

Correct Answer is B

Explanation

Choice A rationale

While understanding the recommended diabetic diet is important for managing type 1 diabetes, it is not the immediate priority for a client who has received no instruction on diabetes management. Without insulin, a person with type 1 diabetes can develop life- threatening diabetic ketoacidosis, regardless of their diet.

Choice B rationale

Administration of insulin is the immediate priority for a client newly diagnosed with type 1 diabetes. In type 1 diabetes, the body does not produce insulin, a hormone that regulates blood sugar levels. Without insulin, blood sugar levels can become dangerously high, leading to diabetic ketoacidosis, a serious condition that requires emergency medical treatment.

Choice C rationale

While exercise is an important part of managing diabetes, it is not the immediate priority for a client newly diagnosed with type 1 diabetes who has received no instruction on diabetes management. Exercise can help regulate blood sugar levels, but without insulin, exercise alone is not sufficient to prevent diabetic ketoacidosis.

Choice D rationale

Urine testing for ketones is an important part of managing type 1 diabetes, especially during illness or stress, when ketone levels can rise quickly. However, it is not the immediate priority for a client newly diagnosed with type 1 diabetes who has received no instruction on diabetes management.

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Choice D rationale

Choice A rationale

Choice B rationale

Choice C rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer an aminoglycoside antibiotic to a client admitted with a diagnosis of acute diverticulitis. What is the priority nursing action?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

The client newly diagnosed with Type 1 diabetes is to be discharged in the morning and has received no instruction on diabetes. What should be the nurse’s teaching priority?

Correct Answer is B

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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