The elderly client is admitted to the intensive care department with severe Hyperglycemic-Hyperosmolar State (HHS). Which collaborative intervention should the nurse include in the plan of care?
Administer intermediate-acting insulin
Infuse 0.9% Normal Saline intravenously
Monitor arterial blood gas results
Perform blood glucose checks daily
The Correct Answer is B
A. Administer intermediate-acting insulin: Intermediate-acting insulin is not used in the treatment of HHS. In HHS, the primary goal is to lower blood glucose levels gradually using short-acting insulin to prevent rapid changes in glucose and fluid shifts.
B. Infuse 0.9% Normal Saline intravenously: IV fluids are a critical part of the treatment for HHS. 0.9% Normal Saline is used to correct dehydration and restore circulatory volume, which is a major concern in HHS. The goal is to gradually rehydrate the client while simultaneously lowering blood glucose levels.
C. Monitor arterial blood gas results: While monitoring arterial blood gases (ABG) is important for assessing acid-base balance, it is not the priority intervention for HHS. The primary focus should be on correcting hyperglycemia and dehydration first.
D. Perform blood glucose checks daily: Blood glucose monitoring should be more frequent than daily in a client with HHS. It is critical to monitor blood glucose levels every hour or as frequently as needed to assess the effectiveness of interventions and guide insulin therapy.
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Related Questions
Correct Answer is B
Explanation
A. Regular: Regular insulin is a short-acting insulin, typically used for mealtime glucose control. It has a short duration of action (4-6 hours) and is not considered long-lasting insulin.
B. Insulin glargine (Lantus): Insulin glargine (Lantus) is a long-acting insulin that provides a steady release of insulin over a 24-hour period, without a peak, making it ideal for basal insulin coverage. It is designed to maintain blood glucose levels consistently throughout the day and night.
C. Insulin aspart (NovoLog): Insulin aspart is a rapid-acting insulin used primarily for mealtime glucose control, and it has a short duration of action, usually around 2-4 hours.
D. Insulin lispro (Humalog): Insulin lispro is a rapid-acting insulin that works quickly to control post-meal blood sugar but is not long-lasting. It typically lasts for about 3-5 hours.
Correct Answer is ["2500"]
Explanation
Calculation:
- Determine the duration of the intake period.
From 0700 to 1900 is 12 hours.
- Convert all fluid intakes to milliliters (mL) using the standard conversions (1 oz = 30 mL, 1 cc = 1 mL, and 1 oz ice chips = 0.5 oz liquid).
8 oz orange juice: 8oz×30mL/oz=240mL
10 cc flush: 10cc×1mL/cc=10mL
8 oz coffee: 8oz×30mL/oz=240mL
1 oz of cream: 1oz×30mL/oz=30mL
12 oz soda: 12oz×30mL/oz=360mL
4 oz chicken broth: 4oz×30mL/oz=120mL
6 oz soda: 6oz×30mL/oz=180mL
8 oz ice chips: 8oz×0.5(conversionfactorforicechips)×30mL/oz=120mL
100 cc/hr IV infusion for 12 hours: 100cc/hr×12hr=1200mL
- Sum all converted fluid intakes.
Total intake (mL) = 240+10+240+30+360+120+180+120+1200
= 2500mL
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