An unresponsive patient with type 2 diabetes is brought to the emergency department and diagnosed with hyperosmolar hyperglycemic syndrome (HHS). The nurse will anticipate the need to

Questions 48

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ATI Leadership Practice B Questions

Question 1 of 5

An unresponsive patient with type 2 diabetes is brought to the emergency department and diagnosed with hyperosmolar hyperglycemic syndrome (HHS). The nurse will anticipate the need to

Correct Answer: B

Rationale: The correct answer is B: insert a large-bore IV catheter. In HHS, patients are severely dehydrated due to high blood sugar levels. Inserting a large-bore IV catheter allows for rapid rehydration with isotonic fluids. This helps to correct the hyperosmolarity and electrolyte imbalances. Giving dextrose (choice A) would worsen hyperglycemia, initiating oxygen (choice C) is not directly related to managing HHS, and administering long-acting insulin like glargine (choice D) is not the initial priority in managing acute HHS.

Question 2 of 5

The nurse has administered 4 oz of orange juice to an alert patient whose blood glucose was 62 mg/dL. Fifteen minutes later, the blood glucose is 67 mg/dL. Which action should the nurse take next?

Correct Answer: A

Rationale: Rationale: The correct answer is A because the patient's blood glucose level has increased slightly, indicating the orange juice is working. Giving more orange juice is appropriate to continue raising the blood glucose level. Administering glucagon (B) is not necessary as the patient's glucose is improving. Eating peanut butter with crackers (C) may be too slow to raise the glucose level. Notifying the healthcare provider (D) is not needed at this point as the patient is responding to the initial intervention.

Question 3 of 5

A client who is nonambulatory notifies the nurse that their trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next?

Correct Answer: D

Rationale: The correct answer is D: Confine the fire. This is the most appropriate action because the nurse's first priority is to ensure the safety of the client by containing the fire to prevent it from spreading and causing harm. By confining the fire, the nurse can help protect the client and other individuals in the vicinity. Activating the fire alarm (choice A) may be necessary but should come after the fire is confined. Extinguishing the fire (choice B) may put the nurse and client at risk without proper training or equipment. Evacuating the client (choice C) should only be done if the fire cannot be quickly and safely confined.

Question 4 of 5

When using an open irrigation technique to irrigate a client's indwelling urinary catheter, which of the following actions should the nurse take?

Correct Answer: B

Rationale: The correct answer is B: Perform the irrigation using a 20-mL syringe. This is the correct action because using a 20-mL syringe allows for precise and controlled instillation of the irrigation fluid into the catheter. Using a smaller syringe helps prevent excessive pressure within the catheter, reducing the risk of trauma or damage to the client's urinary system. A: Positioning the client in a side-lying position is not essential for open irrigation technique, as long as the client is comfortable and the procedure can be safely performed. C: Instilling 15 mL of irrigation fluid with each flush may not be appropriate as the volume needed may vary based on the client's condition. D: Although measuring and recording the amount of irrigant used is important for documentation purposes, it is not the immediate action to ensure the safe and effective irrigation of the catheter.

Question 5 of 5

A client with limited mobility in their lower extremities is at risk for skin breakdown. Which of the following actions should the nurse take to prevent skin breakdown?

Correct Answer: B

Rationale: The correct answer is B: Increase the client's intake of carbohydrates. Adequate nutrition, including carbohydrates, is essential for skin health and wound healing. Carbohydrates provide energy for the body's healing processes. Skin breakdown can be prevented by ensuring the client has a well-balanced diet. A: Placing the client in high-Fowler's position is not directly related to preventing skin breakdown in this scenario. C: Massaging areas of skin that are darker than the surrounding skin tissue with lotion may cause more harm than good, as it can increase the risk of skin breakdown. D: Having the client use a trapeze bar when changing position is important for mobility but does not directly address the prevention of skin breakdown.

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