A client diagnosed with hyperosmolar hyperglycemia nonketonic syndrome (HHNS) was admitted yesterday with a blood glucose level of 700 mg/dL. The clients blood glucose level is now 250 mg/dL. Which intervention should the nurse implement?

Check the client's urine for ketones.

Notify the healthcare provider to obtain order to decreased insulin

Increase the regular insulin drip

Provided client with a regular meal.

Answer and Explanation

The Correct Answer is B

A. Checking urine for ketones is more relevant in DKA, not HHNS, as HHNS typically does not involve ketone production.
B. When blood glucose drops significantly, insulin infusion rates are usually decreased to prevent hypoglycemia and a rapid fall in glucose levels.
C. Increasing the insulin drip could cause hypoglycemia, as the client’s glucose is already decreasing.
D. A regular meal can be given when the client’s glucose levels are more stable and controlled, but meal timing should be coordinated with insulin adjustments.

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Correct Answer is D

Explanation

A. Bradycardia is not typical in hypovolemia; tachycardia is more common as the body compensates for fluid loss.
B. Hypotension, rather than hypertension, occurs due to reduced blood volume.
C. Polyuria is not a feature of hypovolemia; decreased urine output is expected.
D. Cool, clammy skin is a classic sign of hypovolemic shock as blood flow to the skin decreases in response to blood loss.

A. Ensure the drainage tubing is patent and without obstruction. B. Notify the surgeon if the urine is bright red in appearance or has large clots. C. Add the amount of bladder irrigation to the total output. D. Use sterile technique when preparing the irrigation solution. E. Contact the surgeon if the client reports a continual need to void.

Correct Answer is ["A","B","D","E"]

Explanation

A. Patency of the drainage tubing is crucial to prevent blockage and maintain continuous flow.
B. Bright red urine or large clots could indicate bleeding, requiring immediate notification of the surgeon.
C. The amount of irrigation fluid is usually subtracted from the total output to determine true urine output, not added.
D. Using sterile technique helps prevent infection in a postoperative patient.
E. A continual urge to void could indicate bladder spasms or improper catheter placement, and the surgeon should be contacted.

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A client diagnosed with hyperosmolar hyperglycemia nonketonic syndrome (HHNS) was admitted yesterday with a blood glucose level of 700 mg/dL. The clients blood glucose level is now 250 mg/dL. Which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has experienced significant blood loss. Which of the following is a clinical sign of hypovolemia?

Correct Answer is D

Explanation

A nurse is caring for a client who is 1 day postoperative following a transurethral resection of the prostate (TURP) and has a continuous bladder irrigation in place. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

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