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Exhibits

Based on the client's laboratory values at 1600, which are appropriate nursing actions? Select all that apply.

Give the client 15 g of carbohydrates and retest the blood glucose in 15 minutes

Bolus the client with 1 L of 3% sodium chloride solution

Hold the insulin infusion

Decrease the sodium concentration in the IV fluids from 0.9% to 0.45%

Alert the provider of the current blood glucose level.

Add 20 mEq of potassium chloride to the IV fluids.

Start a regular diet

Answer and Explanation

Correct Answer : D,E,F

A. Give the client 15 g of carbohydrates and retest the blood glucose in 15 minutes.
A blood glucose of 250 mg/dL is still high but does not require immediate carbohydrate administration. Carbohydrates are given in cases of hypoglycemia (blood glucose <70 mg/dL) or when transitioning from IV to subcutaneous insulin at lower glucose levels.
B. Bolus the client with 1 L of 3% sodium chloride solution.
The client’s sodium is already elevated (152 mEq/L), and hypertonic saline (3% NaCl) would worsen hypernatremia and increase the risk of neurological complications. Instead, hypotonic fluids (0.45% NaCl) are recommended once intravascular volume is stabilized.
C. Hold the insulin infusion.
HHS is managed with continuous insulin infusion to gradually reduce glucose levels. The blood glucose is still above the target range (250 mg/dL), so insulin should not be stopped prematurely to avoid a rebound in hyperglycemia.
D. Decrease the sodium concentration in the IV fluids from 0.9% to 0.45%.
Once circulatory volume is restored, fluids should be switched to 0.45% sodium chloride to correct hypernatremia and intracellular dehydration. This is a standard part of HHS treatment after initial fluid resuscitation.
E. Alert the provider of the current blood glucose level.
Glucose levels are improving but still high (250 mg/dL), requiring adjustments in fluid and insulin therapy. The provider should be informed to assess whether insulin titration or fluid changes are necessary.
F. Add 20 mEq of potassium chloride to the IV fluids.
Insulin therapy drives potassium into cells, leading to hypokalemia (K⁺ = 3.2 mEq/L), which can cause cardiac arrhythmias and muscle weakness. Potassium replacement is required to prevent complications and maintain normal levels.
G. Start a regular diet.
Clients with HHS require gradual rehydration and glucose control before transitioning to oral intake. A regular diet is not appropriate until the client is stable, glucose levels are consistently controlled, and IV therapy is discontinued.

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Correct Answer is B

Explanation

A. Administer famotidine 20 mg IV. Famotidine is a histamine-2 receptor antagonist used for stress ulcer prophylaxis in critically ill patients. While this medication may be beneficial, it is not the priority intervention based on the insulin protocol and the client's blood glucose level.
B. Titrate insulin infusion by 1 unit/hour. The client’s blood glucose is 160 mg/dL, which falls within the 150–199 mg/dL range according to the insulin protocol. The protocol directs the nurse to increase the insulin drip rate by 1 unit/hour to maintain blood glucose levels below 150 mg/dL. This is the most immediate and appropriate action.
C. Increase dopamine 2 mcg/kg. The client’s MAP is 66 mmHg, which meets the protocol goal of keeping MAP >65 mmHg. There is no indication for increasing dopamine at this time, as the blood pressure is already within the target range.
D. Raise oxygen by 10 percent. The client is on 50% FiO₂ via a face mask with an oxygen saturation of 92%, which is adequate oxygenation for a critically ill patient. Increasing FiO₂ unnecessarily may contribute to oxygen toxicity and is not required based on current oxygenation status.

A. Document that the client is experiencing a paced rhythm. B. Reposition the ECG leads and obtain another recording. C. Assess the client for symptoms of decreased cardiac output. D. Notify the healthcare provider (HCP) of the telemetry recording.

Correct Answer is A

Explanation

A. Document that the client is experiencing a paced rhythm. A pacemaker spike before each QRS complex indicates that the pacemaker is functioning properly and triggering ventricular depolarization as intended. Since the client is 24 hours postoperative from a pacemaker insertion, this is an expected finding and should be documented accordingly.
B. Reposition the ECG leads and obtain another recording. If the ECG showed artifact, lead displacement, or interference, repositioning the leads might be appropriate. However, the presence of consistent pacemaker spikes before each QRS complex suggests proper pacemaker function rather than a lead issue.
C. Assess the client for symptoms of decreased cardiac output. A paced rhythm is expected after pacemaker insertion and does not necessarily indicate hemodynamic instability. While assessment is always important, there is no indication that the client is experiencing decreased cardiac output symptoms such as hypotension, dizziness, or altered mental status.
D. Notify the healthcare provider (HCP) of the telemetry recording. Routine paced rhythms do not require immediate provider notification unless there are malfunctions such as failure to capture, failure to sense, or failure to pace. Since the pacemaker is functioning appropriately, notifying the HCP is unnecessary.

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Exhibits Based on the client's laboratory values at 1600, which are appropriate nursing actions? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse assesses the telemetry monitor of a client who is 24 hours postoperative from having a permanent pacemaker insertion. The nurse observes that a pacemaker spike is present before each QRS complex in lead II of the electrocardiogram (ECG). Which intervention should the nurse implement?

Correct Answer is A

Explanation

A client is admitted to the neurological intensive care unit after having just sustained a C5 spinal cord injury (SCI). Which assessment finding for this client warrants immediate intervention by the nurse?

The nurse assesses a client postoperatively who has an arterial line in the right radial artery. Assessment findings include pallor, paresthesia, and slow capillary refill in the client's right-hand fingers. Which action should the nurse take?

Exhibits Click to mark whether the actions are indicated, contraindicated, or nonessential for this client. Each row must have one option selected.

Exhibits Which other labs would be helpful for the treatment of diabetic ketoacidosis (DKA)? Select all that apply.

Exhibits

Based on the client's laboratory values at 1600, which are appropriate nursing actions? Select all that apply.