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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Shakiness is a classic symptom of hypoglycemia due to adrenaline release as the body responds to low glucose levels.
B. Decreased appetite is not typical of hypoglycemia; in fact, hunger may increase as the body signals the need for energy.
C. Increased thirst is a symptom of hyperglycemia, not hypoglycemia.
D. Skin is typically cool and clammy during hypoglycemia, not warm and moist.
Correct Answer is B
Explanation
A. Weight may fluctuate but is not a direct indication of immediate fluid resuscitation adequacy.
B. A decrease in heart rate is a sign of improved perfusion and stabilization, suggesting that fluid replacement is effective in compensating for blood loss.
C. Adequate fluid replacement is indicated by an increase, not a decrease, in urine output.
D. Blood pressure should stabilize or increase with fluid replacement, rather than decrease.
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