The nurse recognizes which of the following as signs and symptoms of hyperglycemia? (Select All that Apply)

Excessive thirst

Anxiety and tremors

Excessive urination

"Acetone" or "fruity" breath odor

Slow, shallow respirations

Answer and Explanation

Correct Answer : A,C,D

A. Excessive thirst (polydipsia) is a common symptom of hyperglycemia due to dehydration caused by increased urination.
B. Anxiety and tremors are more commonly associated with hypoglycemia (low blood sugar), not hyperglycemia.
C. Excessive urination (polyuria) is a hallmark of hyperglycemia as the body attempts to excrete excess glucose through urine.
D. "Acetone" or "fruity" breath odor is a characteristic sign of diabetic ketoacidosis (DKA), which can occur in severe hyperglycemia.
E. Slow, shallow respirations are not typically associated with hyperglycemia but may occur in cases of respiratory acidosis or DKA, where Kussmaul's breathing (deep, rapid breathing) is more common.

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Correct Answer is A

Explanation

A. Antihypertensive medication is not a priority intervention for a client with a blood glucose level of 620 mg/dL, which indicates hyperglycemia, likely due to diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS). The focus should be on correcting the hyperglycemia and preventing complications like dehydration or electrolyte imbalances.
B. Fluid replacement is essential to treat dehydration caused by hyperglycemia, as high blood glucose levels cause osmotic diuresis.
C. Potassium laboratory monitoring is crucial because insulin treatment can shift potassium into cells, potentially causing hypokalemia, so monitoring is necessary during treatment.
D. Insulin IV infusion is necessary to lower the blood glucose level in clients with severe hyperglycemia, such as in DKA or HHS.

A. Apply a constricting bandage/gauze wrap B. Advise the client they will need an immediate amputation C. Prepare the client to go back to the operating room D. Elevate the extremity and apply ice E. Notify the surgeon

Correct Answer is ["C","E"]

Explanation

A. Applying a constricting bandage/gauze wrap is contraindicated. This could further compromise circulation and exacerbate ischemia.
B. Advising the client about an immediate amputation is inappropriate and outside the nurse's scope of practice. The focus should be on timely intervention and notifying the surgeon.
C. Preparing the client to go back to the operating room is appropriate because the symptoms indicate potential compartment syndrome or vascular compromise, which often requires surgical intervention to restore circulation.
D. Elevating the extremity and applying ice is contraindicated in this scenario. Elevation can further decrease blood flow to an already ischemic limb, and ice application can cause vasoconstriction, worsening the issue.
E. Notifying the surgeon is essential. The described symptoms are a surgical emergency requiring immediate evaluation and intervention to prevent permanent damage.

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The nurse recognizes which of the following as signs and symptoms of hyperglycemia? (Select All that Apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a blood glucose reading of 620 mg/dL. The nurse would expect all of the following interventions except which?

Correct Answer is A

Explanation

Correct Answer is ["C","E"]

Explanation

Which assessment finding is most indicative of hypernatremia?

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