A client with Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS) has a blood glucose level of 925 mg/dL and is confused and lethargic. What is the priority nursing intervention?
Begin IV fluid replacement with normal saline
Prepare for endotracheal intubation
Begin regular insulin IV bolus
Administer 50% dextrose IV push
The Correct Answer is A
Rationale:
A. The priority in HHNS is fluid resuscitation, as severe hyperglycemia causes profound dehydration, hyperosmolarity, and electrolyte imbalances. Rapid IV fluid replacement helps restore circulating volume, improve perfusion, and reduce blood glucose concentration indirectly. Fluids are given before insulin to avoid rapid fluid shifts and hypotension. Correcting dehydration is life-saving and is always the first step in HHNS management.
B. While confusion and lethargy may indicate altered mental status, airway compromise is not typically the immediate priority in HHNS. Intubation is only required if the patient’s airway is at risk due to decreased consciousness or respiratory failure. Immediate fluid resuscitation and stabilization are higher priorities.
C. Insulin therapy is important in HHNS to reduce blood glucose, but starting insulin before fluid replacement can cause rapid shifts in osmolarity, potentially leading to cerebral edema or cardiovascular collapse. Fluids must be administered first, and insulin is usually started after initial hydration.
D. Dextrose is used to treat hypoglycemia, not severe hyperglycemia. In HHNS, blood glucose is extremely high (925 mg/dL), so administering dextrose would worsen hyperosmolarity and exacerbate the patient’s condition. This intervention is completely inappropriate in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. When mixing NPH (intermediate-acting) and Regular (short-acting) insulin, air must first be injected into the NPH vial, then into the Regular vial, before drawing up the insulin. Drawing up the Regular insulin first ensures the short-acting insulin remains uncontaminated by NPH, which could alter its onset and peak. After the Regular insulin is drawn, the NPH dose is drawn, maintaining proper concentrations and ensuring safe, accurate administration.
B. Injecting air into Regular first and drawing Regular before NPH can result in contamination of the short-acting insulin with intermediate-acting insulin. This could affect the insulin’s onset, peak, and duration. Using the wrong sequence increases the risk of improper glucose control.
C. Drawing NPH before Regular increases the risk of contaminating the Regular insulin. Contamination can alter the pharmacokinetics of the short-acting insulin, making blood glucose management unpredictable. This sequence does not follow safe mixing guidelines.
D. Not injecting air into both vials before drawing the insulin can create a vacuum, making it difficult to withdraw the correct doses. This increases the chance of dosing errors and reduces the accuracy of the insulin administered.
Correct Answer is B
Explanation
Rationale:
A. Monitor for signs of hypoglycemia is incorrect because prednisone, a corticosteroid, typically causes hyperglycemia, not hypoglycemia. Corticosteroids increase blood glucose levels by stimulating gluconeogenesis, reducing peripheral glucose uptake, and promoting insulin resistance. Therefore, the client is at increased risk of high blood sugar, not low blood sugar.
B. Prednisone commonly causes significant hyperglycemia, especially in clients with type 2 diabetes mellitus. Because this client is already insulin-dependent, the priority intervention is to anticipate the need for increased insulin dosing and adjust the regimen accordingly. This prevents severe hyperglycemia, diabetic ketoacidosis (DKA), or hyperosmolar hyperglycemic state (HHS). Close monitoring of blood glucose levels and titration of insulin is essential.
C. The dose of prednisone is determined by the provider for asthma management. Increasing the dose without provider direction is unsafe and would worsen hyperglycemia and potential steroid-related complications.
D. Although corticosteroids can cause fluid retention, fluid restriction is not appropriate or safe unless the client has another condition requiring restriction (e.g., heart failure). Managing glucose levels is a much higher priority, and fluid restriction does not prevent steroid-induced hyperglycemia.
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