Nokea
A nurse is providing care for an older adult client who has hyperglycemia, polydipsia, and polyuria. Which of the following manifestations supports the clinical presentation of hyperosmolar hyperglycemic syndrome (HHS)? (Select All that Apply.)
- A. Acetone breath.
- B. Fever.
- C. Serum glucose 800 mg/dL (74 to 106 mg/dL).
- D. Serum bicarbonate 15 mEq/L (21 to 28 mEq/L).
- E. Insidious onset.
Correct Answer: B,C,E
Rationale: Fever, serum glucose of 800 mg/dL, and insidious onset are characteristic of HHS, often triggered by infection and marked by extreme hyperglycemia without significant ketoacidosis.
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Phenazopyridine hydrochloride turns the urine which color?
- A. Purple.
- B. Orange.
- C. Blue.
- D. Green.
Correct Answer: B
Rationale: Phenazopyridine hydrochloride turns the urine orange, a common and harmless side effect due to its dye properties.
A nurse is caring for a client who has a prescription for clopidogrel. Which of the following actions should the nurse plan to take?
- A. Administer the medication with each meal.
- B. Initiate contact precautions.
- C. Have suction equipment at the bedside.
- D. Monitor the client for black, tarry stools.
Correct Answer: D
Rationale: Monitoring for black, tarry stools is crucial as clopidogrel increases bleeding risk, indicating potential gastrointestinal bleeding.
A nurse is collecting data from a client whose arterial blood gas values reveal a pH of 7.24, PaCO₂ of 53, and an HCO₃ of 24. The nurse should prepare to treat the client for which of the following acid-base imbalances?
- A. Metabolic acidosis.
- B. Metabolic alkalosis.
- C. Respiratory acidosis.
- D. Respiratory alkalosis.
Correct Answer: C
Rationale: Low pH (7.24) and high PaCO₂ (53) indicate respiratory acidosis due to CO₂ accumulation from inadequate ventilation.
A nurse is collecting data for a client who has fluid volume deficit. Which of the following is an expected finding?
- A. Increased urine ketones.
- B. Increased urine specific gravity.
- C. Decreased hematocrit.
- D. Decreased urine output.
Correct Answer: B
Rationale: Increased urine specific gravity is expected in fluid volume deficit, indicating concentrated urine due to decreased fluid intake or excessive fluid loss.
A nurse is reinforcing dietary instructions with a client who has episodes of biliary colic from chronic cholecystitis. Which of the following diets should the nurse reinforce in the teaching plan?
- A. A high protein diet.
- B. A high fiber diet.
- C. A low sodium diet.
- D. A low fat diet.
Correct Answer: D
Rationale: A low fat diet is recommended for clients with biliary colic from chronic cholecystitis as it reduces the workload on the gallbladder and decreases the risk of gallstone formation.