When a client is first admitted with hyperglycemic hyperosmolar syndrome (HHS), the nurse's priority action is which of the following?
Select one:

Carbohydrates

Dietary instruction

Fluid replacement

Oxygen

Answer and Explanation

The Correct Answer is C

A. Carbohydrates are not appropriate at this stage; the client is hyperglycemic and requires glucose-lowering interventions, not additional carbohydrates.
B. Dietary instruction is important for long-term management but is not a priority during the acute phase of HHS, which is a medical emergency.
C. Fluid replacement is the priority. Clients with HHS experience extreme dehydration due to osmotic diuresis. Rapid IV fluid administration is essential to restore perfusion, correct hypotension, and prevent shock.
D. Oxygen may be used if the client has respiratory distress, but it is not the primary intervention in HHS, where dehydration is the most urgent concern.

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Correct Answer is D

Explanation

A. Completing an incident report is important for documentation and quality improvement, but it is not the immediate priority.
B. Contacting the provider is appropriate after assessing the patient’s current status.
C. Administering a carbohydrate snack may be necessary if the blood glucose is low, but it should be guided by actual glucose results.
D. The priority is to assess the client’s current blood glucose level to determine if hypoglycemia is developing due to unnecessary insulin administration. This ensures that timely corrective measures can be taken based on the actual reading.

A. Connect the patient to a cardiac monitor B. Administer IV fluids as ordered C. Place the patient in a supine position and notify the provider D. Document the findings and continue to monitor

Correct Answer is C

Explanation

A. While monitoring is important, it is not the priority when the patient is symptomatic with hypotension and dizziness.
B. IV fluids may be necessary to treat hypotension, but positioning the patient safely and notifying the provider comes first to prevent falls or further deterioration.
C. The patient is showing signs of orthostatic hypotension and compensatory tachycardia. Placing the patient in a supine position helps restore cerebral perfusion and stabilize blood pressure. Immediate notification of the provider allows for prompt medical intervention.
D. Documentation and monitoring are important, but intervention is needed immediately due to symptomatic hypotension.

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When a client is first admitted with hyperglycemic hyperosmolar syndrome (HHS), the nurse's priority action is which of the following? Select one:

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Naxlex Comprehensive Predictor Exams

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Select one: