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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is A
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A. Monitoring for occult blood in the stool is essential because long-term use of nonsteroidal anti- inflammatory drugs (NSAIDs) like ibuprofen can increase the risk of gastrointestinal bleeding and ulceration. Occult blood in the stool may indicate gastrointestinal bleeding, which can be a serious complication of chronic NSAID use.
B. While NSAIDs like ibuprofen can affect renal function and increase the risk of kidney damage, they are not directly associated with alterations in blood glucose levels.
C. Ibuprofen use is not typically associated with alterations in serum calcium levels
D. While monitoring urine for white blood cells may be relevant in the context of renal injury, it is not as specific or sensitive as other tests such as urinalysis or renal function tests.
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