The nurse observes a novice nurse caring for a client experiencing status epilepticus. It will require immediate intervention if the novice nurse does which of the following?

Activates the rapid response team (RRT).

Loosens any restrictive clothing.

Places the client in a lateral position.

Prepares to administer intravenous valproate acid.

Answer and Explanation

The Correct Answer is D

Choice A rationale: Activates the rapid response team (RRT) - Status epilepticus is a medical emergency requiring immediate intervention. Activating the rapid response team would ensure a prompt response to the situation.

Choice B rationale: Loosens any restrictive clothing - It is important for patient safety and comfort.

Choice C rationale: Places the client in a lateral position - This is a recommended positioning to prevent aspiration during a seizure.

Choice D rationale: Prepares to administer intravenous valproate acid - Valproic acid is not the first drug during epilepsy hence this action would necessitate immediate intervention.

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Correct Answer is D

Explanation

Choice A rationale: This may indicate a different condition such as gastroenteritis rather than Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS).

Choice B rationale: This is more indicative of diabetic ketoacidosis (DKA) rather than HHNS.

Choice C rationale: A 72-year-old with a history of diabetes, elevated blood glucose, and complaints of thirst and frequent urination might have uncontrolled diabetes, but the absence of severe hyperglycemia and other symptoms specific to HHNS makes this choice less likely.

Choice D rationale: This fits the criteria for HHNS. The infection, missed medication, and extremely high blood glucose levels suggest the possibility of Hyperglycemic Hyperosmolar Nonketotic Syndrome.

A. Assess the client urine output (UOP) B. Obtain a 12-lead electrocardiogram (ECG) C. Notify the primary healthcare provider (PMHCP) D. Stop the regular insulin infusion

Correct Answer is C

Explanation

Choice A rationale: Assessing the UOP is important, but not as urgent as correcting the potassium imbalance.

Choice B rationale: Obtaining a 12-lead ECG can help monitor the cardiac status, but it does not address the cause of the problem.

Choice C rationale: The PMHCP can order potassium replacement to prevent cardiac arrhythmias and other adverse effects of low potassium levels.

Choice D rationale: Stopping the regular insulin infusion can worsen the DKA and increase the risk of cerebral edema and coma.

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The nurse observes a novice nurse caring for a client experiencing status epilepticus. It will require immediate intervention if the novice nurse does which of the following?

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Naxlex Comprehensive Predictor Exams

Which of the following patients is most likely experiencing Hyperglycemic Hyperosmolar Nonketotic Syndrome based on their symptoms?

Correct Answer is D

Explanation

The nurse is caring for a client with diabetic ketoacidosis (DKA) receiving intravenous (IV) regular insulin. The most recent potassium was 2.9 mEq/L. The nurse should take which priority action:

Correct Answer is C

Explanation

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