Which of the following evaluation data would the nurse recognize that a patient with hyperosmolar hyperglycemic syndrome (HHS) has improved during the first 24 hours upon admission to the hospital?
Alert and oriented, blood and urine without ketones, no orthostatic blood pressure changes.
Alert and oriented, balanced intake and output, moist mucous membranes.
Respirations easy and unlabored, eats 50-75% of meals, vital signs stable.
Equal intake and output, denies pain or shortness of breath.
The Correct Answer is A
A. Alert and oriented, blood and urine without ketones, no orthostatic blood pressure changes – These findings indicate improved hydration, resolution of hyperosmolarity, and recovery of neurological function, key markers of HHS improvement.
B. Alert and oriented, balanced intake and output, moist mucous membranes – While improved hydration is good, ketone clearance and hemodynamic stability are more important indicators.
C. Respirations easy and unlabored, eats 50-75% of meals, vital signs stable – Respiratory status is not the primary concern in HHS.
D. Equal intake and output, denies pain or shortness of breath – These signs do not specifically indicate resolution of HHS.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. High glucose levels cause the body to use proteins for energy, causing lactic acidosis – While hyperglycemia can lead to ketosis, it does not directly cause lactic acidosis.
B. Chronic elevated blood glucose levels damage cells and cause long-term chronic organ dysfunction – Hyperglycemia leads to complications such as neuropathy, nephropathy, and retinopathy, making glucose control essential.
C. Early identification of hypoglycemia is easier to treat resulting in better outcomes – While important, the primary reason for frequent monitoring is to prevent long-term complications.
D. Carbohydrates are constantly being converted to glucose and utilized for extra energy stores – This statement is not specific to diabetes management.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Answer: The nurse should first address the patient’s oxygen saturation followed by the patient’s hypotension.
Rationale:
1st Priority: Oxygen Saturation → The client’s oxygen saturation has dropped to 88% on room air, which is below the expected range (typically ≥95% in healthy individuals). Hypoxia must be addressed immediately to prevent further complications. The nurse should apply supplemental oxygen and reassess respiratory status.
2nd Priority: Hypotension → The client’s blood pressure has dropped to 94/59 mmHg, which is significantly lower than the earlier reading of 102/76 mmHg. This may contribute to dizziness and syncope. The nurse should monitor for signs of hemodynamic instability, assess for ongoing blood loss (related to heavy menstrual bleeding), and anticipate interventions such as IV fluids or further evaluation for anemia-related hypotension.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.