Exhibits
Nursing actions: Indicated/contraindicated/non-urgent
Teach the client how to count carbohydrates
Stop the insulin infusion
Decrease the frequency of blood glucose tests
Start the client on a regular diet
Decrease the insulin IV infusion to 0.05 units/kg/hr
The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}
A. Teach the client how to count carbohydrates - Non-urgent. While essential for long- term management of diabetes, carbohydrate counting is not immediately critical in the acute management phase of HHS in the ICU. This teaching should be delayed until the patient is stabilized.
B. Stop the insulin infusion - Contraindicated. Stopping insulin in a patient with HHS, which is characterized by severe hyperglycemia, would be harmful. Insulin therapy is critical to reduce blood glucose levels safely.
C. Decrease the frequency of blood glucose tests - Contraindicated. Frequent monitoring is crucial in managing HHS, especially when insulin therapy is being administered, to prevent hypoglycemia and to monitor the effectiveness of treatment.
D. Start the client on a regular diet - Contraindicated. Introducing a regular diet during the acute phase of HHS could exacerbate the hyperglycemia. Nutritional needs should be assessed and managed carefully, typically starting with IV fluids and gradually transitioning to enteral or oral feeding as the patient stabilizes.
E. Decrease the insulin IV infusion to 0.05 units/kg/hr- Indicated. As blood sugar levels decrease, the insulin infusion rate may be cautiously reduced to prevent hypoglycemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E"]
Explanation
A. Bending from the waist to pick up trash can cause imbalance and strain; it is safer to bend at the knees.
B. Leaning forward to pull a pan from a high shelf can lead to loss of balance; using a step stool is safer.
C. Locking the knees can lead to loss of balance and is not a recommended posture.
D. Widening the stance provides a stable base and helps maintain balance while working.
E. Bringing a heavy can close to the body before lifting uses proper body mechanics, reducing the risk of strain and promoting balance.
Correct Answer is B
Explanation
A. A blood alcohol level of 0.09% indicates intoxication but is less immediately critical than lithium toxicity.
B. A serum lithium level of 1.6 mEq/L indicates lithium toxicity, which can be life- threatening and requires immediate medical intervention.
C. Significant weight loss is concerning but not as acute an issue as potential lithium toxicity.
D. Lack of sleep is serious but is a symptom that can be managed; it is not as urgent as addressing potential lithium toxicity.
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