A nurse is instructing a client who has left-sided hemiparesis about the use of a quad cane. Which of the following actions by the client indicates an understanding of the teaching?

• Urine ketones:

They are commonly present in DKA due to the breakdown of fats as an alternative energy source when insulin is insufficient. Ketones in urine are a hallmark sign of DKA.

Ketones may not be present in urine in HHS because insulin levels are sufficient to prevent excessive breakdown of fats. Therefore, urine ketones are more specific to DKA.

• Creatinine greater than expected reference range

DKA: In DKA, dehydration and electrolyte imbalances can lead to acute kidney injury (AKI), resulting in elevated creatinine levels.

HHS: Elevated creatinine can also occur in HHS due to severe dehydration and reduced kidney perfusion.

• Blood glucose greater than expected reference range:

DKA: Extremely high blood glucose levels (typically >250 mg/dL) are a hallmark of DKA due to insulin deficiency and the resultant inability to transport glucose into cells for energy.

HHS: Similar to DKA, HHS is characterized by extremely high blood glucose levels (often >600 mg/dL). Therefore, elevated blood glucose levels are consistent with both DKA and HHS.

• Skin turgor

DKA: Decreased skin turgor is indicative of dehydration, which is common in DKA due to excessive urination (polyuria) and fluid loss.

HHS: Similarly, decreased skin turgor can also be seen in HHS due to profound dehydration caused by excessive hyperglycemia and osmotic diuresis.

• Blood pH greater than expected reference range

DKA: DKA is characterized by metabolic acidosis, leading to a decreased blood pH (<7.35). Therefore, a pH greater than expected reference range would not be typical for DKA.

HHS: HHS, on the other hand, is characterized by severe hyperglycemia without significant ketoacidosis. Patients with HHS can have a normal or even elevated blood pH (>7.45) due to compensation mechanisms and absence of significant acidosis.

D. This sequence is important because regular insulin should not be contaminated with NPH insulin, and drawing up regular insulin first helps ensure accurate dosing and prevents mixing of the two insulins prematurely.

A Insulin injections are typically administered subcutaneously, which usually requires a 90-degree angle (perpendicular) for needle insertion, especially if the person has adequate subcutaneous tissue.

B. Prefilled insulin syringes should be stored with the needle pointing upward to prevent insulin leakage or air bubbles from affecting the accuracy of the dose.

C NPH (Neutral Protamine Hagedorn) insulin is a suspension and should not be vigorously shaken. Shaking could cause frothing or denaturation of the insulin, affecting its efficacy and consistency.