A patient with Type 2 diabetes is brought into the emergency room in an unresponsive state.
Vital signs include BP: 88/56, HR: 122, RR 16, Sp 95% and glucose of 720 mg/dL. A diagnosis of Hyperosmolar Hyperglycemic Syndrome (HHS) is made.The nurse prepares for the administration of which priority therapy?

Administration of Glucagon.

Dextrose 50%.

0.45% Normal Saline IV.

0.9% saline solution IV.

Answer and Explanation

The Correct Answer is D

Choice D rationale

Hyperosmolar Hyperglycemic Syndrome (HHS) is a serious complication of diabetes that occurs when blood sugar levels are extremely high. The primary treatment for HHS is intravenous fluids and insulin. Specifically, 0.9% saline solution IV is often used initially to restore volume and correct severe dehydration.

Choice A rationale

Administration of Glucagon is not the primary treatment for HHS. Glucagon is a hormone that raises blood glucose levels and would not be beneficial in a situation where blood glucose is already extremely high.

Choice B rationale

Dextrose 50% is a concentrated glucose solution and would not be appropriate in the treatment of HHS, where blood glucose levels are already dangerously high.

Choice C rationale

While IV fluids are a crucial part of the treatment for HHS, 0.45% Normal Saline (also known as half-normal saline) is a hypotonic solution and is not typically the first choice for fluid resuscitation in HHS. The preferred initial fluid is often 0.9% saline (normal saline), which is isotonic.

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Correct Answer is A

Explanation

Choice A rationale

After a femoral-popliteal bypass, the client should be placed in a supine position with the right leg extended and flat. This position helps to prevent kinking and occlusion of the graft, which could lead to complications such as graft thrombosis.

Choice B rationale

High-Fowler’s position with the right leg extended is not recommended. This position could put strain on the surgical site and potentially compromise the graft.

Choice C rationale

Supine with the right leg flexed at a 45-degree angle is not advised. Flexing the leg could lead to kinking of the graft and subsequent complications.

Choice D rationale

Semi-Fowler’s with the right leg on two pillows is not the optimal position. While elevation can help with swelling, excessive elevation could potentially compromise blood flow to the graft.

A. Administer the PRN antianxiety medication. B. Call the rapid response team. C. Increase the intravenous infusion rate. D. Prepare for mechanical ventilation.

Correct Answer is B

Explanation

Choice A rationale

Administering the PRN antianxiety medication is not the most appropriate next step. The client’s symptoms—shortness of breath, anxiety, restlessness, tachycardia, tachypnea, hypotension, and decreased oxygen saturation—are indicative of a potential pulmonary embolism, a life-threatening complication of deep vein thrombosis. While anxiety can be a symptom of a pulmonary embolism, treating it without addressing the underlying cause could delay necessary medical intervention.

Choice B rationale

Calling the rapid response team is the most appropriate next step. The client’s symptoms suggest a potential pulmonary embolism, a serious and life-threatening condition that requires immediate medical intervention. The rapid response team can provide the necessary urgent care.

Choice C rationale

Increasing the intravenous infusion rate is not the most appropriate next step. While hydration is important, it would not address the immediate life-threatening situation. The client’s symptoms suggest a potential pulmonary embolism, which requires immediate medical intervention.

Choice D rationale

Preparing for mechanical ventilation is not the most appropriate next step. While the client’s decreased oxygen saturation and increased respiratory rate suggest respiratory distress, the priority should be to address the potential pulmonary embolism. Mechanical ventilation may be necessary later depending on the client’s response to treatment.

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Choice D rationale

Choice A rationale

Choice B rationale

Choice C rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has just returned to the surgical unit following a femoral-popliteal bypass of the right leg. In which position should the nurse place the client?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Correct Answer is B

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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