A nurse is assessing a client who is experiencing a hyperglycemic hyperosmolar state. Which of the following findings should the nurse expect? (Select all that apply)
Absence of urine ketones.
Blood glucose 685 mg/dL (74 to 106 mg/dL).
BUN 8 mg/dL (10 to 20 mg/dL).
Fruity breath odor.
Dehydration.
Correct Answer : A,B,E
Choice A reason: Absence of urine ketones is expected in hyperglycemic hyperosmolar state (HHS). Unlike diabetic ketoacidosis (DKA), HHS does not involve significant ketone production because insulin levels are usually sufficient to prevent lipolysis and ketogenesis.
Choice B reason: Blood glucose levels in HHS are extremely elevated, often exceeding 600 mg/dL. A value of 685 mg/dL is consistent with this condition and reflects the severe hyperglycemia that drives osmotic diuresis and dehydration.
Choice C reason: A BUN of 8 mg/dL is within normal range and would not be expected in HHS. Typically, BUN is elevated due to dehydration and reduced renal perfusion. Therefore, this finding is not consistent with HHS.
Choice D reason: Fruity breath odor is characteristic of diabetic ketoacidosis due to acetone accumulation from ketone metabolism. It is not expected in HHS, which lacks significant ketosis.
Choice E reason: Dehydration is a hallmark of HHS. Severe hyperglycemia causes osmotic diuresis, leading to profound fluid loss, hemoconcentration, and electrolyte imbalance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Premature atrial complexes are usually benign and do not require cardioversion. They are often managed with observation or medication if symptomatic.
Choice B reason: Ventricular fibrillation requires immediate defibrillation, not synchronized cardioversion, because there is no organized rhythm to synchronize with.
Choice C reason: Atrial fibrillation in a hemodynamically unstable client is correct. Synchronized cardioversion delivers a shock timed with the R wave to restore sinus rhythm and prevent deterioration.
Choice D reason: Ventricular asystole is a flatline rhythm and requires CPR and epinephrine, not cardioversion. Shocking asystole is ineffective.
Correct Answer is A
Explanation
Choice A reason: Determining the client’s living situation is the first priority because it establishes the baseline context for care planning. The nurse must assess whether the client lives alone, with family, or in a facility, and evaluate accessibility, safety, and support systems. This information guides all subsequent interventions and ensures that recommendations are tailored to the client’s environment.
Choice B reason: Problem solving with the client is important, but it should occur after the nurse has gathered essential information about the client’s living situation. Without this assessment, problem solving may be ineffective or misaligned with the client’s actual needs.
Choice C reason: Offering community resources is a later step in the process. Resources should be matched to the client’s specific circumstances, which cannot be determined until the nurse understands the living situation. Therefore, this option is premature as the first action.
Choice D reason: Assisting the client with decision-making is valuable, but decisions must be informed by a thorough assessment of the client’s environment and needs. Without this foundation, decision-making may lack relevance or practicality.
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