A client is admitted with a serum glucose of 618mg/dl. The client is awake and oriented, with hot, dry skin; a temperature of 100.6F (38.1 C); a heart rate of 116beats/min; and a blood pressure of 108/70mmHg. Based on these findings, which nursing diagnosis takes highest priority?

Correct Answer: A

Rationale: The highest priority nursing diagnosis in this scenario is Deficient fluid volume related to osmotic diuresis. The client's serum glucose level of 618mg/dl indicates severe hyperglycemia, which is likely causing osmotic diuresis leading to fluid volume deficit. The client's hot, dry skin, along with a heart rate of 116 beats/min, and blood pressure of 108/70mmHg are symptoms of dehydration due to fluid loss. If left untreated, deficient fluid volume can lead to serious complications such as hypovolemic shock. Therefore, addressing the fluid volume deficit is essential to stabilize the client's condition before other nursing diagnoses are addressed.

Correct Answer: D

Rationale: The most likely cause of her chief complaint this morning is a frequent complication of the hypophysectomy. A hypophysectomy is the surgical removal of the pituitary gland. One common complication following a hypophysectomy is diabetes insipidus, characterized by polyuria (excessive urination) and polydipsia (excessive thirst). This occurs because the removal of the pituitary gland can disrupt the regulation of antidiuretic hormone (ADH), which plays a key role in maintaining water balance in the body. Therefore, it is the most likely cause of the patient's chief complaint of polyuria this morning.

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Correct Answer: C

Rationale: Bacon contains the highest kilocalories among the food choices provided. Bacon is high in fat, with approximately 42 kilocalories per slice (8 grams) compared to other options like an apple (52 kilocalories), chicken (231 kilocalories), and bread (79 kilocalories). The high fat content in bacon contributes to its higher caloric value compared to the other choices listed. As such, bacon is the food choice with the highest kilocalorie content in this selection.

Correct Answer: A

Rationale: The correct report from the RN in this situation would be option A. This report accurately describes the situation by mentioning that the potassium bag is piggybacked into the dextrose at 75 ml/h, stating that the clamp should be closed below the D5 ½ NS bag, and clarifying that potassium is on the secondary line. Additionally, the statement that 75 ml will infuse in one hour is also correct based on the infusion rate provided in the question. Therefore, option A is the most appropriate and accurate report to provide in this scenario.