A nurse is caring for a client who has type 2 diabetes mellitus, and their glucose levels are rising. Which of the following would indicate the client is in a hyperosmolar hyperglycemic state (HHS)?

Hypertension

Glucose level of 400 mg/dL

Serum osmolarity of 350 mOsm/L

Ketosis

Answer and Explanation

The Correct Answer is C

A. Hypertension is not a defining feature of HHS.
B. While glucose levels are elevated in HHS, a level of 400 mg/dL alone is not sufficient to diagnose HHS.
C. A serum osmolarity greater than 320 mOsm/L is characteristic of HHS, reflecting severe dehydration and hyperosmolarity.
D. Ketosis is typically absent or minimal in HHS, distinguishing it from diabetic ketoacidosis (DKA).

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Correct Answer is D

Explanation

A. A tight seal between the lips and mouthpiece is necessary to effectively use the incentive spirometer.
B. Inhalation should be slow and deep, not rapid, to maximize lung expansion.
C. The breath should be held for about 3 to 5 seconds, not 20 seconds, to prevent dizziness.
D. Sitting up or elevating the head of the bed improves lung expansion and enhances the effectiveness of the incentive spirometer.

A. "I'll splint my incision with a pillow to cough." B. "I'll breathe deeply and cough every 4 hours." C. "I'll ask for pain medication after I do the exercises." D. "I'll use the incentive spirometer when I can get out of bed."

Correct Answer is A

Explanation

A. Splinting the incision with a pillow helps reduce pain and allows more effective coughing.
B. Deep breathing and coughing should be performed more frequently than every 4 hours, usually every 1-2 hours.
C. Pain medication should be taken before performing exercises to facilitate effective breathing and coughing, not after.
D. The incentive spirometer should be used frequently, including while in bed, not only after getting out of bed.

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A nurse is caring for a client who has type 2 diabetes mellitus, and their glucose levels are rising. Which of the following would indicate the client is in a hyperosmolar hyperglycemic state (HHS)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing a preoperative teaching plan about using an incentive spirometer. Which of the following should the nurse include in the teaching plan?

Correct Answer is D

Explanation

A nurse instructs a preoperative client on how to perform deep-breathing exercises and cough effectively after surgery. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

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