A nurse is caring for a client who has a new onset of hyperglycemic hyperosmolar state (HHS). Which of the following interventions by the nurse is the highest priority?

Initiate IV fluid replacement.

Measure the client's urinary output.

Administer insulin.

Teach the client about manifestations of HHS

Answer and Explanation

The Correct Answer is A

A.   Initiate IV fluid replacement is the highest priority intervention. HHS is characterized by severe dehydration due to osmotic diuresis resulting from hyperglycemia. IV fluid replacement is essential to correct dehydration and restore intravascular volume, which can help improve tissue perfusion and prevent further complications.
B.   Monitoring urinary output is important in assessing renal function and response to fluid replacement therapy. However, it is not the highest priority intervention.
C.   While insulin therapy is an essential part of managing hyperglycemia in HHS, it is not the highest priority intervention at the immediate onset of HHS.

D.   Patient education about the manifestations and management of HHS is important for long-term management and prevention of recurrence. However, it is not the highest priority when the client is experiencing an acute episode of HHS.

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Correct Answer is B

Explanation

The transverse colon is located across the right upper quadrant, epigastrium and the left upper quadrant.

A. Titrate IV fluids to maintain urine output at 75 mL/hr. B. Administer an opioid pain medication, C. Change dressings over the entrance and exit wounds. D. Obtain an ECG

Correct Answer is D

Explanation

D. Obtaining an electrocardiogram (ECG) is the first action to take when managing a client with an electrical shock injury. Electrical shock injuries can cause cardiac dysrhythmias, including ventricular fibrillation or other life-threatening arrhythmias. Therefore, obtaining an ECG allows for prompt assessment of cardiac rhythm and identification of any dysrhythmias that may require immediate intervention.
A. While fluid resuscitation may be necessary in the management of electrical shock injuries to address hypovolemia and promote renal perfusion, titrating IV fluids to maintain a specific urine output is not the first action to take.
B. Pain management is important in the care of clients with electrical shock injuries, but it is not the first action to prioritize
C. Changing dressings over the entrance and exit wounds is important for wound care, but it is not the first action to take.

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A nurse is caring for a client who has a new onset of hyperglycemic hyperosmolar state (HHS). Which of the following interventions by the nurse is the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse in the emergency department is managing the care of a client who has an electrical shock injury. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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