WITH CORRECT ANSWERS 2026-2027
The client diagnosed with type 2 diabetes is admitted to the intensive care unit with hyperosm
olar hyperglycemic nonketonic syndrome (HHNS) coma. Which assessment data should the nur
se expect the client to exhibit?
1. Kussmaul's respirations.
2. Diarrhea and epigastric pain.
3. Dry mucous membranes.
4. Ketone breath odor. - CORRECT ANSWER -
3.Dry mucous membranes are a result of the hyperglycemia and occur with both HHNS and DK
A.
The elderly client is admitted to the intensive care department diagnosed with severe HHNS.
Which collaborative intervention should the nurse include in the plan of care?
1. Infuse 0.9% normal saline intravenously.
2. Administer intermediate-acting insulin.
3. Perform blood glucometer checks daily.
4. Monitor arterial blood gas results. - CORRECT ANSWER -
1. The initial fluid replacement is 0.9%normal saline (an isotonic solution) intravenously, followe
d by 0.45% saline.The rate depends on the client's fluid volume status and physical health, esp
ecially of the heart.
Which electrolyte replacement should the nurse anticipate being ordered by thehealth-
care provider in the client diagnosed with DKA who has just been admitted tothe ICU?
1. Glucose.
2. Potassium.
3. Calcium.
, 4. Sodium - CORRECT ANSWER -
2. The client in DKA loses potassium fromincreased urinary output, acidosis, cata-
bolic state, and vomiting. Replacementis essential for preventing cardiac dys-
rhythmias secondary to hypokalemia
The client diagnosed with HHNS was admitted yesterday with a blood glucose level of 780 mg/
dL. The client's blood glucose level is now 300 mg/dL. Which intervention should the nurse im
plement?
1. Increase the regular insulin IV drip.
2. Check the client's urine for ketones.
3. Provide the client with a therapeutic diabetic meal.
4. Notify the HCP to obtain an order to decrease insulin. - CORRECT ANSWER -
4. When the glucose level is decreased to around 300 mg/dL, the regular insulin infusion thera
py is decreased. Subcutaneous insulin will be administered per sliding scale.
The client diagnosed with type 1 diabetes is found lying unconscious on the floor of the bathro
om. Which intervention should the nurse implement first?
1. Administer 50% dextrose IVP.
2. Notify the health-care provider.
3. Move the client to the ICU.
4. Check the serum glucose level. - CORRECT ANSWER -
1. The nurse should assume the client is hypoglycemic and administer IVP dextrose, which will
rouse the client immediately. If the collapse is the result of hyperglycemia, this additional dext
rose will not further injure the client.
Which assessment data indicate the client diagnosed with diabetic ketoacidosis is responding t
o the medical treatment?