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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:

A. Manages activities of daily living independently: Preserving functional independence is not a direct clinical outcome related to managing chronic pyelonephritis. The primary concern with this condition is preserving renal function and preventing long-term complications like hypertension.

B. Measures oral temperature daily: Monitoring temperature can help detect infections early, but chronic pyelonephritis may not always present with fever. It’s a short-term strategy and less critical than preventing progression to renal damage or cardiovascular complications.

C. Maintains blood pressure within normal limits: Chronic pyelonephritis can lead to kidney scarring, which often contributes to secondary hypertension. Controlling blood pressure is vital in slowing renal deterioration and preventing cardiovascular events, making it the most important long-term goal.

D. Restricts fluid intake to 1 L/day: Fluid restriction is not appropriate unless the client is in advanced kidney failure with fluid overload. Adequate hydration is usually encouraged to help flush bacteria from the urinary tract and support renal function.

A. noticeable facial droop B. garbled speech C. few drinks at a local seafood restaurant D. speech became difficult to understand.

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

Explanation

Rationale for correct Choices:

Noticeable facial droop: Facial drooping is a hallmark sign of a stroke. Early recognition is critical because prompt intervention, such as thrombolytic therapy, must occur within a narrow time window to prevent long-term neurological damage.
Garbled speech: Slurred or incomprehensible speech (dysarthria or aphasia) is another acute stroke symptom. It indicates potential involvement of the brain's language centers and requires immediate neuroimaging and evaluation.
Speech became difficult to understand: A sudden change in speech pattern strongly suggests an evolving neurologic event such as a transient ischemic attack (TIA) or stroke. Timely identification of symptom onset is essential for determining eligibility for time-sensitive stroke treatments like alteplase.

Rationale for Incorrect Choices:

Few drinks at a local seafood restaurant: While alcohol can cause slurred speech and sea food can result in allergic reaction, the patient reports with symptoms suggestive of a stroke, therefore this is not part of the immediate concerns.

View Question and Answer

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

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

Which long-term outcome is most important for the nurse to include in the plan of care for an older adult client with chronic pyelonephritis?

Correct Answer is C

Explanation

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

Explanation

The nurse is reviewing a pregnant client's prenatal immunization history. Which immunization should the nurse instruct the client to receive after pregnancy?

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having unprotected sex. Which response should the nurse provide?

Exhibits For each of the findings listed, click to indicate which are consistent with the disease process of aortic aneurysm versus gastric cancer. Each column must have at least one response option selected.