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NCLEX questions for MidTerm Exam 2 with complete solution
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A patient is brought to the emergency department in a comatose state after developing hyperosmolar hyperglycemic non-ketotic syndrome (HHNS). The nurse begins her care and assessment of this patient. What is the nurse's first priority in this situation? a)Providing isotonic fluid replacement...

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  • 7. april 2022
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  • a patient is brought to the emergency department in a comatose state after developing hyperosmolar hyperglycemic non ketotic syndrome hhns the nurse begins her ca

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NCLEX questions for MidTerm Exam 2

A patient is brought to the emergency department in a comatose state after developing
hyperosmolar hyperglycemic non-ketotic syndrome (HHNS). The nurse begins her care
and assessment of this patient. What is the nurse's first priority in this situation?

a)Providing isotonic fluid replacement

b) Maintaining the patients cervical spine

c) Administering insulin IM

d) Monitoring serum chloride levels Correct answer- a)Providing isotonic fluid
replacement

In the intensive care unit, the nurse cares for a client who has been admitted with
diabetic ketoacidosis. The client is on a continuous
infusion of regular insulin at 5 units/hr via IV pump. Which actions should the nurse
expect to implement? Select all that apply.

1. Administer potassium supplement when serum potassium is 3.5-5.0 mEq/L (3.5-5.0
mmoi/L)

2. Discontinue insulin infusion when fingerstick blood glucose is <350 mg/dl

3. Increase the insulin infusion rate when blood glucose level decreases

4. Monitor fingerstick or serum blood glucose every hour

5. Start infusion of dextrose 5% water when blood glucose is <250 mg/dl (13.9 mmoi/L)
Correct answer- 1, 4, 5

Insulin shifts the potassium back into the
intracellular space. As a result, serum potassium levels will then begin to decrease once
insulin is started. This client is on a
continuous insulin drip so serum potassium will continue to decrease. When serum
potassium is normal, a potassium supplement
(usually in the form of an IV piggyback) should be added to the medication regimen to
prevent impending hypokalemia (K+ <3.5 mEq/L
[3.5 mmoi/L]) (Option 1). Low potassium (hypokalemia) can cause muscle weakness,
cramps, fatigue, and life-threatening cardiac
arrhythmias.

,When the client is on an insulin drip, a fingerstick or serum blood glucose level should
be checked at least hourly (Option 4). D5W is
added to the IV fluid when blood glucose is <250 mg/dl (13.9 mmoi/L) to prevent a
hypoglycemic reaction with regular (short-acting)
IV insulin (Option 5). Insulin and D5W should be continued until the acidosis resolves.
The insulin infusion is titrated down as blood
glucose is lowered (Option 3); it is discontinued when the client is switched to
subcutaneous injections. This generally occurs when
blood glucose is <200 mg/dl (11.1 mmoi/L) and there is no evidence of metabolic
acidosis (Option 2).

The nurse cares for a client diagnosed with type I diabetes mellitus who came to the
emergency department with the acute
complication of diabetic ketoacidosis (DKA). After checking the blood glucose, which
prescription should the nurse implement first?
1. Insert an indwelling urinary catheter for accurate output calculation
2. Obtain serum potassium level results and report to the primary health care provider
3. Prepare an insulin drip for intravenous (IV) infusion as prescribed
4. Start an IV line and infuse normal saline as prescribed Correct answer- 1

The priority intervention in DKA is to start an IV infusion for bolus rehydration therapy
with normal saline. This should
occur before insulin infusion as insulin will result in water, potassium, and glucose
entering the cells, worsening the dehydration and
electrolyte imbalances.

A client with type I diabetes mellitus is brought to the emergency department by his
wife. The client has fruity breath with rapid, deep respirations at 36 breaths per minute,
reports abdominal pain, and appears weak. The nurse should anticipate implementation
of
which prescription(s)? Select all that apply.

1. Administer dextrose 50 mg intravenous (IV) push
2. Instruct client to breathe into a paper bag to treat hyperventilation
3. Perform a fingerstick and serum blood glucose test
4. Prepare to administer an IV infusion of regular insulin
5. Start an IV line and administer a bolus of normal saline Correct answer- 3, 4, 5

The client is exhibiting the cardinal signs and symptoms of diabetic ketoacidosis (DKA).
DKA is an acute life-threatening
complication, typically of type I diabetes, characterized by hyperglycemia, ketosis, and
acidosis. It is caused by an intense deficit of
insulin. Because some of the symptoms of hypoglycemia and DKA overlap, a blood
glucose level should be checked to ensure that hyperglycemia is present.Option 1
would make the situation worse, and option 2 is inappropriate as the client is acidotic
and needs to blow off the acid.

,A client is diagnosed with diabetic ketoacidosis (DKA). The client reports frequent
urination, thirst, and weakness. The nurse
assesses a temperature of 102.4 F (39.1 C), fruity breath, deep labored respirations
with a rate of 30/min, and dry mucous
membranes. What is the priority nursing diagnosis (ND) at this time?
1. Deficient fluid volume related to osmotic diuresis
2. Imbalanced nutrition, less than body requirements related to inability to metabolize
glucose
3. Ineffective breathing pattern related to the presence of metabolic acidosis
4. Ineffective health maintenance related to the inability to manage DM during illness
Correct answer- Option 1

Deficient fluid volume related to osmotic diuresis secondary to hyperglycemia as
evidenced by dry mucous membranes and client report of frequent urination, thirst, and
weakness is the priority ND. Hyperglycemia leads to osmotic diuresis, dehydration,
electrolyte imbalance, and possible hypovolemic shock and renal failure. Therefore, this
condition requires rapid correction through the infusion
of isotonic intravenous fluids and poses the greatest risk to the client's survival (Option 1
).

The nurse is caring for an adolescent client diagnosed with type 1 diabetes. The client
exhibits hot, dry skin and a glucose level of
350 mg/dL (19.4 mmoi/L). Arterial blood gases show a pH of 7.27. STAT serum
chemistry labs have been drawn. Cardiac monitoring shows a sinus rhythm with peaked
T waves, and the client has minimal urine output. What is the nurse's next priority
action?

1 . Administer IV regular insulin
2. Administer normal saline infusion
3. Obtain urine for urinalysis
c 4. Request prescription for potassium infusion Correct answer- Option 2

Potassium should never be given until the serum potassium level is known to be normal
or low and urinary voiding is
observed. Peaked T waves indicate hyperkalemia in this client. Clients with insulin
deficiency frequently have increased serum
potassium levels due to the extracellular shift despite having total body potassium deficit
from urinary losses. Once insulin is given,
serum potassium levels drop rapidly, often requiring potassium replacement. Potassium
is never given as a rapid IV bolus, as cardiac
arrest may result.
Educational objective:
Clients with diabetic ketoacidosis and hyperosmolar hyperglycemic state require IV
normal saline as a priority due to severe dehydration. Once fluids are given as a bolus,
insulin is initiated. The serum potassium levels can be elevated in the initial stages

, despite a low total body potassium. Potassium repletion is started once the serum
potassium levels are normalized or trending low
(from elevated levels).

A nurse is caring for 4 clients. Which prescription by the health care provider would the
nurse question and seek further clarification
before administering?

1. 0.45% sodium chloride solution for a client with severe gastroenteritis who had 12
episodes of diarrhea and vomiting in the
past 4 hours

2. IV bolus of 1000 ml 0.9% sodium chloride solution for a client in anaphylaxis due to a
food allergy

3. IV bolus of 1000 ml 0.9% sodium chloride solution for a client with diabetic
ketoacidosis who has a serum glucose level of 650 mg/dl (36.1 mmoi/L)

4. IV mannitol 25°/o solution for a client with a closed head injury who is exhibiting signs
of increased intracranial pressure Correct answer- Option 1

The nurse should question the administration of a hypotonic IV solution (ie, 0.45o/o
sodium chloride) to replace gastrointestinal tract
fluid losses as this would create a concentration gradient and shift fluid out of the
intravascular compartment into the interstitial tissue
and cells, worsening the client's fluid volume deficit. Isotonic IV solutions (eg, 0.9%
sodium chloride, lactated Ringer's) have the same osmolality as plasma and are
administered to expand intravascular fluid volume. These solutions replace fluid losses
commonly associated with vomiting and diarrhea, burns, and traumatic injury.
(Option 2) Anaphylaxis causes increased capillary permeability, leaking intravascular
fluid into free spaces; this places the client at risk for hypotension. Therefore, isotonic
solutions should be given to such clients.
(Option 3) Extreme hyperglycemia in a client with diabetic ketoacidosis results in
osmotic diuresis and dehydration. The immediate
initial treatment is IV fluid resuscitation with isotonic 0.9o/o sodium chloride to replace
fluid losses, stabilize vital signs, reestablish urine
output, and dilute the serum glucose concentration before initiating insulin therapy.
(Option 4) A client with head trauma is at risk for increased intracranial pressure due to
inflammation and cerebral edema. IV mannitol is an osmotic diuretic that reduces
cerebral edema by pulling water from the cerebral cells into the vasculature.

The nurse is making assignments for the next shift. Which client should the nurse
assign to the new nurse coming out of orientation?
1. Client diagnosed with chronic anemia receiving iron via IV route [53%]
2. Client newly admitted for uncontrolled diabetes mellitus type 2 with blood glucose
>600 mg/dl (33.3 mmoi/L) [3o/o]

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