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 D

Explanation

Choice A rationale

The Trendelenburg position, with the stump supported on three pillows, is not typically recommended following a below-the-knee amputation. This position could increase the risk of contractures.

Choice B rationale

Side lying with the amputated leg flexed is not typically recommended following a below-the- knee amputation. This position could increase the risk of contractures.

Choice C rationale

Lying prone for 24 hours is not typically recommended following a below-the-knee amputation. While some prone positioning may be beneficial to prevent hip flexion contractures, it should not be the only position used.

Choice D rationale

The supine position, with the stump flat on the bed, is often recommended following a below- the-knee amputation. This position helps to prevent contractures and promotes healing.

A. “My feet look reddish when I put them down.”. B. “I noticed that the hair on my feet and legs is gone.”. C. “My legs were so cold I had to put a heating pad on them.”. D. “My legs start to hurt when I walk to get my mail.”.

Correct Answer is C

Explanation

Choice A rationale

Reddish feet when put down could be a sign of dependent rubor, a condition that occurs due to peripheral arterial disease (PAD). When the legs are in a dependent (downward) position, gravity aids in delivering blood to the area, causing a reddish color. However, this is a common symptom of PAD and does not require immediate intervention.

Choice B rationale

Loss of hair on the feet and legs is another symptom of PAD1. This happens because inadequate blood flow deprives the hair follicles of the nutrients they need to grow. While this symptom indicates worsening PAD, it does not warrant immediate intervention.

Choice C rationale

Applying a heating pad to cold legs could lead to burns because PAD can cause loss of sensation in the legs. This warrants immediate intervention to prevent injury.

Choice D rationale

Leg pain during walking, also known as claudication, is a common symptom of PAD1. This happens because the muscles are not getting enough oxygen due to reduced blood flow.

However, this symptom does not require immediate intervention but should be evaluated further.

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Choice D rationale

Choice A rationale

Choice B rationale

Choice C rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has just returned to the nursing unit following a below-the-knee amputation (BKA) of the right leg. How should this client be positioned?

Correct Answer is D

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

The nurse is caring for a patient with a diagnosis of chronic peripheral arterial disease. Which statement by the patient warrants immediate intervention by the nurse?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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