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Patient Data

The second liter of fluids is administered. The nurse reassesses the client to see how effective the fluid resuscitation was. Which finding(s) indicate(s) that the client has improved with fluid resuscitation? Select all that apply.

Partial pressure of oxygen of 50 mm Hg

Positive result on passive leg raise challenge

Peripheral pulses of 2+

Mixed venous oxygen saturation of 70%

Mean arterial pressure (MAP) between 70 to 80 mm Hg

Central venous pressure of 9 mm Hg

Urine output greater than 0.5 mL/kg/hour

Capillary refill of greater than 3 seconds

Answer and Explanation

Correct Answer : B,C,D,E,F,G

Rationale:

A. Partial pressure of oxygen of 50 mm Hg: A PaO₂ of 50 mm Hg is below the normal range (80–100 mm Hg) and indicates hypoxemia. This does not reflect improvement with fluid resuscitation and would require supplemental oxygen or further interventions.

B. Positive result on passive leg raise challenge: A positive response indicates that the client is fluid responsive, meaning cardiac output increases with fluid administration. This reflects improved perfusion and effective intravascular volume expansion.

C. Peripheral pulses of 2+: Palpable, normal-strength pulses suggest improved perfusion to the extremities following fluid resuscitation. This indicates that intravascular volume and cardiac output have been enhanced.

D. Mixed venous oxygen saturation of 70%: A SvO₂ around 70% reflects adequate oxygen delivery relative to tissue oxygen consumption. This indicates that perfusion and oxygenation have improved after fluids.

E. Mean arterial pressure (MAP) between 70 to 80 mm Hg: MAP in this range demonstrates adequate systemic perfusion. Restoration of MAP is a key goal of fluid resuscitation in septic or hypovolemic states.

F. Central venous pressure of 9 mm Hg: CVP in the range of 8–12 mm Hg suggests adequate right-sided filling and intravascular volume after fluid administration.

G. Urine output greater than 0.5 mL/kg/hour: Adequate urine output is an important indicator of improved renal perfusion and intravascular volume following fluid resuscitation.

H. Capillary refill of greater than 3 seconds: Prolonged capillary refill indicates poor peripheral perfusion. Improvement would be reflected by capillary refill of ≤2 seconds, so a value >3 seconds does not indicate improvement.

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Correct Answer is ["A","B","D"]

Explanation

Rationale:
A. Titrate infusion of regular insulin per protocol: Continuous IV insulin is the cornerstone of HHS management to reduce hyperglycemia gradually. Careful titration prevents rapid shifts in glucose that can cause cerebral edema or other complications.

B. Monitor daily serum electrolyte levels: Electrolyte imbalances, especially potassium, are common in HHS due to dehydration and insulin therapy. Monitoring allows timely replacement and prevents cardiac arrhythmias or neuromuscular complications.

C. Check peripheral tissues for edema: Peripheral edema is not a typical concern in HHS, which primarily causes intracellular dehydration. Monitoring for edema is not a priority in the acute management of HHS.

D. Enact seizure precautions with seizure pads: Severe hyperosmolarity and electrolyte disturbances can precipitate neurological complications, including seizures. Precautions protect the client from injury if a seizure occurs.

E. Implement every 4 hour serial blood sugar levels: Checking blood sugar levels every 4 hours is inadequate for a client receiving a continuous IV insulin infusion for a life-threatening hyperglycemic crisis. Standard of care for HHS requires hourly blood glucose monitoring to allow for the safe titration of the insulin drip and to prevent the complications of hypoglycemia.

A. Administer famotidine 20 mg IV. B. Raise oxygen by 10 percent. C. Increase dopamine 2 mcg/kg. D. Titrate insulin infusion by 1 unit/hour.

Correct Answer is D

Explanation

Rationale:
A. Administer famotidine 20 mg IV: Famotidine is used for stress ulcer prophylaxis in critically ill clients but does not address the current protocol-driven abnormalities. The client’s immediate issues relate to glucose control, hemodynamics, and oxygenation.

B. Raise oxygen by 10 percent: The client’s oxygen saturation is 92% on 50% oxygen, which is acceptable in the setting of critical illness and MODS. There is no evidence of acute hypoxemia requiring escalation at this time. Oxygen therapy adjustments are not prioritized when saturation goals are being met.

C. Increase dopamine 2 mcg/kg/min: Dopamine is being titrated to maintain a MAP greater than 65 mm Hg, and the current MAP is 66 mm Hg, meeting the target. Increasing dopamine could unnecessarily raise heart rate and myocardial oxygen demand. No titration is indicated while the hemodynamic goal is achieved.

D. Titrate insulin infusion by 1 unit/hour: The blood glucose level of 160 mg/dL falls within the 150–199 mg/dL range, which requires an increase in insulin infusion by 1 unit/hour per protocol. Adjusting the insulin drip maintains tight glycemic control, which is essential in MODS to reduce infection risk and improve outcomes.

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Patient Data The second liter of fluids is administered. The nurse reassesses the client to see how effective the fluid resuscitation was. Which finding(s) indicate(s) that the client has improved with fluid resuscitation? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Which intervention(s) should the nurse include in the plan of care (POC) for a client who is admitted with hyperosmolar hyperglycemic syndrome (HHS)? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

Correct Answer is D

Explanation

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Patient Data

The second liter of fluids is administered. The nurse reassesses the client to see how effective the fluid resuscitation was. Which finding(s) indicate(s) that the client has improved with fluid resuscitation? Select all that apply.