A client who has type 2 diabetes mellitus is admitted to the intensive care unit with third degree burns over 20% of the body. To decrease the client's risk of developing hyperosmolar hyperglycemic syndrome (HHS), which intervention(s) should the nurse implement? Select all that apply.

Assess for breath with a fruity odor.

Titrate an insulin infusion to maintain a low serum glucose level.

Monitor for elevated temperature and administer PRN antipyretics.

Monitor serum electrolyte levels and report any abnormal values.

Maintain large bore IV patency for aggressive fluid resuscitation.

Answer and Explanation

Correct Answer : B,D,E

Rationale:
A. Assess for breath with a fruity odor: This is more indicative of diabetic ketoacidosis (DKA), not HHS. HHS does not usually produce ketones or fruity-smelling breath, so it is not a priority assessment for this condition.

B. Titrate an insulin infusion to maintain a low serum glucose level: Maintaining glucose control through insulin infusion is critical in preventing HHS, as the syndrome is driven by severe hyperglycemia without ketosis.

C. Monitor for elevated temperature and administer PRN antipyretics: While fever management is important for burn care, it does not directly prevent HHS, which is primarily a result of fluid imbalance and hyperglycemia.

D. Monitor serum electrolyte levels and report any abnormal values: Electrolyte disturbances are common in HHS due to dehydration and osmotic diuresis. Prompt correction is essential to prevent complications.

E. Maintain large bore IV patency for aggressive fluid resuscitation: Massive fluid loss from burns and hyperglycemia requires aggressive IV fluid replacement to prevent dehydration and hemoconcentration, both of which contribute to HHS.

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

Explanation

Rationale:
A. Encourage activity as tolerated: Gradual mobilization supports respiratory function, circulation, and muscle strength after prolonged intubation. Activity also helps reduce the risk of complications like atelectasis and deep vein thrombosis.

B. Assess ability to swallow solids and liquids: After extended intubation, clients are at risk for dysphagia, which can lead to aspiration pneumonia. A swallowing assessment is necessary to ensure safety before resuming a regular oral diet.

C. Assist client with active range of motion: Prolonged immobility in the ICU often leads to deconditioning and muscle weakness. Assisting with range of motion exercises promotes circulation, prevents contractures, and maintains joint flexibility.

D. Reinforce deep breathing exercises: Deep breathing promotes alveolar expansion, improves oxygenation, and prevents postoperative complications such as pneumonia or atelectasis, which are particularly concerning after extubation and in clients with COPD.

E. Obtain dietary consult for meal supplements: Poor appetite post-extubation can contribute to malnutrition and delayed recovery. A dietary consult ensures the client receives adequate caloric and protein intake through appropriate supplements.

A. She is a gravida 6, para 5. B. She received butorphanol 2 mg IV during labor. C. She is over 35 years of age. D. The second stage of labor lasted 10 minutes.

Correct Answer is A

Explanation

Rationale:

A. She is a gravida 6, para 5: A high parity (multiple previous births) stretches the uterus significantly over time, increasing the risk of uterine atony—a leading cause of postpartum hemorrhage due to the uterus failing to contract effectively.

B. She received butorphanol 2 mg IV during labor: Butorphanol is a narcotic analgesic and does not directly contribute to excessive postpartum bleeding or uterine atony in typical doses.

C. She is over 35 years of age: Advanced maternal age can increase some obstetric risks, but it is not as directly associated with postpartum hemorrhage as high parity.

D. The second stage of labor lasted 10 minutes: A short second stage may lead to perineal trauma, but it is less likely to cause excessive vaginal bleeding compared to uterine atony from high parity.

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A client who has type 2 diabetes mellitus is admitted to the intensive care unit with third degree burns over 20% of the body. To decrease the client's risk of developing hyperosmolar hyperglycemic syndrome (HHS), which intervention(s) should the nurse implement? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult with pneumonia and an exacerbation of chronic obstructive pulmonary disease (COPD) was intubated for 14 days and was sucessfully extubated yesterday. Currently, the client has a weak cough and poor appetite. Which intervention(s) should the nurse implement? Select all that apply.

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

Explanation

When assessing a recently delivered, multigravida client, the nurse finds that her vaginal bleeding is more than expected. Which factor in this client's history is related to this finding?

Correct Answer is A

Explanation

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