A nurse is providing care for an older adult client who has hyperglycemia, polydipsia, and polyuria. Which of the following manifestations supports the clinical presentation of hyperosmolar hyperglycemic syndrome (HHS)? (Select All that Apply.)

Acetone breath.

Fever.

Serum glucose 800 mg/dL (74 to 106 mg/dL).

Serum bicarbonate 15 mEq/L (21 to 28 mEq/L).

Insidious onset.

Answer and Explanation

Correct Answer : B,C,E

Choice A rationale
Acetone breath is a characteristic symptom of diabetic ketoacidosis (DKA), not hyperosmolar hyperglycemic syndrome (HHS). In DKA, the body produces ketones, leading to a fruity or acetone-like breath odor. HHS, on the other hand, does not typically involve significant ketone production.
Choice B rationale
Fever can be a manifestation of HHS, often due to an underlying infection or illness that precipitates the hyperglycemic state. Infections are common triggers for HHS, leading to elevated body temperature.
Choice C rationale
Serum glucose levels of 800 mg/dL are indicative of HHS. HHS is characterized by extremely high blood glucose levels, often exceeding 600 mg/dL, without significant ketoacidosis.
Choice D rationale
Serum bicarbonate levels of 15 mEq/L are more indicative of DKA rather than HHS. In HHS, bicarbonate levels are usually within the normal range because there is no significant ketoacidosis.
Choice E rationale
Insidious onset is a hallmark of HHS. The condition develops gradually over days to weeks, unlike DKA, which has a more rapid onset.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale
Kernig’s sign is associated with meningitis, not hypocalcemia. It involves pain and resistance when attempting to extend the leg at the knee while the hip is flexed.
Choice B rationale
Brudzinski’s sign is also associated with meningitis, not hypocalcemia. It involves involuntary lifting of the legs when lifting a patient’s head.
Choice C rationale
Chvostek’s sign is a clinical sign of hypocalcemia. It involves twitching of the facial muscles in response to tapping over the facial nerve.
Choice D rationale
Cullen’s sign is associated with acute pancreatitis and involves bruising around the umbilicus. It is not related to hypocalcemia.

A. Respiratory alkalosis. B. Respiratory acidosis. C. Metabolic acidosis. D. Metabolic alkalosis.

Correct Answer is B

Explanation

Choice A rationale
Respiratory alkalosis is incorrect. Respiratory alkalosis is characterized by a high pH and low PaCO₂, which is not consistent with the given ABG values. The client’s pH is low (7.22), indicating acidosis, and the PaCO₂ is high (68 mm Hg), indicating a respiratory cause.
Choice B rationale
Respiratory acidosis is correct. Respiratory acidosis occurs when there is an accumulation of carbon dioxide (CO₂) in the blood, leading to a decrease in pH. The given ABG values show a low pH (7.22) and a high PaCO₂ (68 mm Hg), which are indicative of respiratory acidosis. The elevated bicarbonate (28 mEq/L) suggests partial compensation by the kidneys.
Choice C rationale
Metabolic acidosis is incorrect. Metabolic acidosis is characterized by a low pH and low bicarbonate (HCO₃⁻) levels. In this case, the bicarbonate level is elevated (28 mEq/L), which is not consistent with metabolic acidosis. The primary issue is respiratory, as indicated by the high PaCO₂.
Choice D rationale
Metabolic alkalosis is incorrect. Metabolic alkalosis is characterized by a high pH and high bicarbonate levels. The given ABG values show a low pH (7.22), which indicates acidosis, not alkalosis. Additionally, the primary issue is respiratory, as indicated by the high PaCO₂.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is providing care for an older adult client who has hyperglycemia, polydipsia, and polyuria. Which of the following manifestations supports the clinical presentation of hyperosmolar hyperglycemic syndrome (HHS)? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who has hypocalcemia. For which of the following signs should the nurse monitor?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

A nurse is contributing to the plan of care for an older adult client who has a WBC of 2000/mm³ after three rounds of chemotherapy. Which of the following interventions should the nurse include in the plan?

A nurse is reinforcing teaching with a female client about preventing urinary tract infections (UTIs). Which of the following instructions should the nurse include?

A nurse is admitting a client who reports recurrent flank pain and nausea for 24 hr. Which of the following actions should the nurse take first?

A nurse is reviewing the urinalysis results of a client who reports urinary frequency and burning. Which of the following findings should the nurse report to the provider?

A client who is taking nitrofurantoin for a urinary tract infection voices a concern to the clinic nurse about voiding brown-colored urine. Which of the following is an appropriate response by the nurse?

A nurse is contributing to the plan of care for a client who is postoperative following a total hip arthroplasty. Which of the following information should the nurse include?

A nurse is collecting data from a client who has pulmonary tuberculosis. Which of the following findings should the nurse expect?

A nurse is preparing to administer ondansetron 4 mg IM stat. The amount available is ondansetron for injection 2 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. (Do not use a trailing zero)