The nurse is caring for a patient with hyperosmolar hyperglycemic syndrome. The patient is receiving intravenous fluids of normal saline with 20 mEq of potassium chloride and a continuous insulin infusion. Which finding will indicate to the nurse that the treatment is effective?
Normal blood pressure, deep respirations
Increased alertness, normal heart rhythm
High urine specific gravity, normal temperature
Blood glucose of 250 mg/dL, disorientation
The Correct Answer is B
Choice A reason: Normal blood pressure and deep respirations do not necessarily indicate that hyperosmolar hyperglycemic syndrome is resolving. Deep respirations, also known as Kussmaul respirations, can occur in response to severe hyperglycemia.
Choice B reason: Increased alertness and a normal heart rhythm suggest that the patient's neurological status and cardiovascular system are stabilizing, which are positive indicators that the treatment is effective in managing hyperosmolar hyperglycemic syndrome.
Choice C reason: High urine specific gravity and normal temperature do not directly indicate the effectiveness of treatment for hyperosmolar hyperglycemic syndrome. High urine specific gravity can result from dehydration.
Choice D reason: A blood glucose level of 250 mg/dL with disorientation still indicates poorly controlled hyperglycemia and ongoing metabolic disturbance, which means the treatment is not yet effective.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
Choice A reason: Applying a hypothermia blanket is appropriate for managing hyperthermia in a patient with Graves' disease. Elevated temperatures (fever) are common in thyroid storm, a severe complication of Graves' disease. Using a hypothermia blanket helps reduce the body temperature and prevent further complications.
Choice B reason: Administering humidified oxygen is important for supporting respiratory function in a patient with increased respiratory rate and decreased level of consciousness. Humidified oxygen can help alleviate respiratory distress and improve oxygenation.
Choice C reason: Administering aspirin 325 mg orally is not recommended for patients with hyperthyroidism or thyroid storm. Aspirin can increase free thyroid hormone levels by displacing thyroid hormone from its binding proteins, potentially worsening the patient's condition. Acetaminophen is a safer alternative for managing fever in these patients.
Choice D reason: Administering D5NS intravenous infusion is appropriate for managing dehydration and electrolyte imbalances in a patient with thyroid storm. This intervention helps maintain fluid balance and provides dextrose for energy.
Choice E reason: Administering propylthiouracil is a key intervention for managing thyroid storm. Propylthiouracil inhibits thyroid hormone synthesis and peripheral conversion of T4 to T3, helping to reduce thyroid hormone levels and alleviate symptoms.
Correct Answer is ["A","C","E"]
Explanation
Choice A reason: Ulcers in the descending colon are indicative of Crohn's disease, which affects any part of the gastrointestinal tract.
Choice B reason: Absence of narrowing of the colon and mucosal edema is more indicative of ulcerative colitis rather than Crohn's disease.
Choice C reason: Fistulas and perianal involvement are common complications of Crohn's disease due to the transmural inflammation.
Choice D reason: Mild bleeding and an abdominal mass can be associated with both Crohn's disease and other gastrointestinal disorders, making it less specific.
Choice E reason: Regional, discontinuous skip lesions are a hallmark of Crohn's disease, seen on barium studies, indicating areas of inflammation separated by normal tissue.
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