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
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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Related Questions
Correct Answer is C
Explanation
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.
Correct Answer is D
Explanation
A. While pain medication may be necessary, assessing the cause of symptoms takes priority before any intervention.
B. Repositioning may help improve lung expansion but should only be done after assessing the client’s status.
C. Incentive spirometry is important postoperatively but should follow an assessment to ensure safety.
D. The first priority is to assess vital signs and oxygen saturation to determine if the client is experiencing respiratory distress or a serious complication such as a pulmonary embolism or pneumothorax, which can present with chest pain and difficulty breathing after laparoscopic surgery.
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