Patient Data
Click to mark whether the nursing action is indicated, contraindicated, or non-urgent. Each row must have one option selected.

Teach the client how to count carbohydrates

Decrease the insulin IV infusion to 0.05 units/kg/hr

Draw electrolyte levels

Decrease the frequency of blood glucose tests

Start the client on a regular diet

Stop the insulin infusion

Change the IV fluids to 0.45% sodium chloride with 5% dextrose

Answer and Explanation

The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"B"},"G":{"answers":"A"}}

Rationale:

• Decrease the insulin IV infusion to 0.05 units/kg/hr: The client’s blood glucose levels are steadily decreasing, indicating that the insulin infusion is effective. In HHS, insulin rates are reduced once glucose levels approach the target range to prevent overly rapid declines that can increase the risk of cerebral edema and hypoglycemia. Careful titration supports safe glucose correction.

• Draw electrolyte levels: HHS causes significant osmotic diuresis, leading to electrolyte imbalances, particularly potassium shifts once insulin therapy is initiated. Frequent electrolyte monitoring is necessary to detect and correct abnormalities early and prevent cardiac and neuromuscular complications.

• Change the IV fluids to 0.45% sodium chloride with 5% dextrose: As blood glucose approaches 250–300 mg/dL, dextrose-containing fluids are added to prevent hypoglycemia while allowing continued insulin administration. Hypotonic saline supports ongoing rehydration while avoiding rapid osmolar shifts that could worsen neurologic status.

• Teach the client how to count carbohydrates: Diabetes self-management education is essential but is not a priority during the acute management of HHS. The client is still critically ill and requires stabilization before education can be effective and safely implemented.

• Decrease the frequency of blood glucose tests: Hourly blood glucose monitoring is essential during IV insulin therapy to guide titration and prevent hypoglycemia. Reducing monitoring frequency could delay detection of dangerous glucose changes during this critical phase.

• Start the client on a regular diet: Clients with HHS are typically kept NPO or on limited intake until metabolic stability is achieved. Starting a regular diet prematurely can worsen hyperglycemia and complicate insulin and fluid management.

• Stop the insulin infusion: Insulin infusion must be continued until hyperosmolarity resolves and blood glucose is consistently controlled. Stopping insulin too early can lead to rebound hyperglycemia and delay resolution of HHS.

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Free Nursing Study Resources

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

Rationale:

• Infection: The client exhibits fever (101.2 °F), leukocytosis (WBC 20,000/mm³), neutrophilia (72%), and a recent surgical wound with redness, swelling, and tenderness, all indicative of a potential postoperative infection. Infection is the most immediate concern because it can rapidly progress to systemic inflammatory response syndrome (SIRS) or sepsis, particularly in older adults.

• Perfusion: The client has hypotension (BP 118/74 mm Hg), tachycardia (126 beats/min), weak distal pulses, and prolonged capillary refill (4 seconds), suggesting impaired tissue perfusion. Early recognition and monitoring of perfusion are critical to prevent organ dysfunction and shock. Nursing care will include fluid management, hemodynamic monitoring, and assessment of end-organ function to maintain adequate perfusion.

• Pain: While the client reports moderate pain (5/10), pain management is secondary to addressing infection and perfusion deficits. Pain control is important but does not take priority over life-threatening systemic issues.

• Oxygenation: Oxygen saturation is 94% on room air, slightly below normal but not immediately critical. Although monitoring oxygenation is part of routine care, it is not the primary focus compared with infection and perfusion concerns in this client.

• Ventilation: The client’s respiratory rate is mildly elevated (22 breaths/min), but there is no evidence of respiratory compromise such as hypoventilation or distress. Ventilation is not the primary concern at this time, as systemic infection and perfusion issues pose more immediate risk.

A. Place bed in the reverse. Trendelenburg position. B. Raise the head of the bed to a 90 degree angle. C. Encourage bed rest until analgesic takes effect. D. Provide a bedside table for client to lean across.

Correct Answer is D

Explanation

Rationale:

A. Place bed in the reverse Trendelenburg position: This position does not specifically relieve pancreatic pain and may increase discomfort by altering abdominal organ positioning without supporting the client’s preferred posture.

B. Raise the head of the bed to a 90 degree angle: Upright positioning alone may not provide adequate support or comfort for the client who finds pain relief by leaning forward and flexing the trunk.

C. Encourage bed rest until analgesic takes effect: Pancreatic pain is often severe and position-dependent; forcing bed rest ignores an effective nonpharmacologic pain-relief strategy and may increase distress.

D. Provide a bedside table for client to lean across: Leaning forward reduces tension on the inflamed pancreas and decreases pain. Supporting this position enhances comfort and complements analgesic therapy.

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Patient Data Click to mark whether the nursing action is indicated, contraindicated, or non-urgent. Each row must have one option selected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Drag from Word Choices to complete the sentence. The nurse anticipates that the primary areas of the client's plan of care will be dropdown and dropdown.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

A client diagnosed with pancreatitis reports severe epigastric pain. After administering a narcotic analgesic, the client insists on sitting up and leaning forward. Which action should the nurse implement?

Correct Answer is D

Explanation

The rapid response team transfers a client with sepsis to the intensive care unit (ICU). The client's white blood cell count is 28,000/mm3 (28 x 10^9/L). Which intervention should the nurse implement first? Reference Range: White blood cell (WBC) [5,000 to 10,000/mm3 (5 to 10 x 10^9/L)]

A client is receiving cardiopulmonary resuscitation (CPR). After asystole is confirmed in two leads and sending for the code cart, which IV medication should be administered?

In addition to the pharmacological treatment, which action(s) could the nurse do to help to optimize the client's cerebral perfusion pressure? Select all that apply.

Consent is obtained to perform a diagnostic thoracentesis for a client with left side pleural effusion. The client is alert, cooperative, and anxious. The nurse should assist the client into which position immediately prior to the procedure?

The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone secretion (SIADH) who was admitted to the intensive care unit (ICU) yesterday. Which intervention is most important for the nurse to include in the client's plan of care (POC)?

Patient Data
Click to mark whether the nursing action is indicated, contraindicated, or non-urgent. Each row must have one option selected.