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 D

Explanation

Choice A rationale

While discussing the need for weight loss can be an important part of managing Type 2 diabetes, it should not necessarily be the initial step when developing an educational plan. Weight loss can help improve blood glucose control, but it’s just one aspect of a comprehensive diabetes management plan15.

Choice B rationale

Inviting the client’s family to participate in the program can be beneficial, as it can provide additional support for the client. However, the initial step in developing an educational plan should focus on the client’s understanding and perception of their diagnosis15.

Choice C rationale

Demonstrating how to check glucose using capillary blood glucose monitoring is an important skill for managing Type 2 diabetes. However, before teaching this skill, it’s important to assess the client’s understanding and readiness to learn15.

Choice D rationale

Assessing the client’s perception of what it means to live with diabetes should be the initial step when developing an educational plan. Understanding the client’s perspective can help tailor the education to meet their needs and improve their ability to manage their diabetes15.

A. Heparin makes the blood less thick and easier to flow. B. Heparin dissolves the clot and decreases the formation of platelets. C. Heparin does not thin the blood; it prevents new clots from forming. D. Heparin decreases the number of platelets so the blood flows more easily.

Correct Answer is C

Explanation

Choice A rationale

Heparin does not actually thin the blood or make it less thick. Instead, it works by increasing the activity of antithrombin, a protein that inhibits blood clotting. This prevents new clots from forming and existing clots from growing larger.

Choice B rationale

Heparin does not dissolve clots or decrease the formation of platelets. Its primary action is to increase the activity of antithrombin, which in turn inactivates thrombin and factor Xa, two key players in the blood clotting process.

Choice C rationale

This statement is accurate. Heparin does not thin the blood; instead, it prevents new clots from forming and existing clots from growing larger. It does this by increasing the activity of antithrombin, which in turn inactivates thrombin and factor Xa.

Choice D rationale

Heparin does not decrease the number of platelets or make the blood flow more easily. Its primary action is to increase the activity of antithrombin, which in turn inactivates thrombin and factor Xa.

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Choice D rationale

Choice A rationale

Choice B rationale

Choice C rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has recently been diagnosed with Type 2 diabetes. What should be the nurse’s initial step when developing an educational plan?

Correct Answer is D

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A patient diagnosed with deep vein thrombosis asks the nurse, “How does this blood thinner heparin work?” Which response is most accurate?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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