an unresponsive patient with type 2 diabetes is brought to the emergency department and diagnosed with hyperosmolar hyperglycemic syndrome hhs the nur

ATI RN

ATI Leadership Practice B

1. 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

A. give a bolus of 50% dextrose.
B. insert a large-bore IV catheter.
C. initiate oxygen via nasal cannula.
D. administer glargine (Lantus) insulin.

Correct answer: B

Rationale: In a patient with hyperosmolar hyperglycemic syndrome (HHS), severe dehydration and electrolyte imbalances are common. To address these issues, the priority intervention is to insert a large-bore IV catheter for fluid resuscitation and electrolyte replacement. Giving a bolus of 50% dextrose would worsen the hyperglycemia. Initiating oxygen via nasal cannula may be beneficial for respiratory support but is not the priority in this scenario. Administering glargine (Lantus) insulin is not the initial treatment for HHS as it does not address the underlying severe dehydration and electrolyte imbalances.

2. An RN enters a patient�s room to place an indwelling urinary catheter, as ordered by the health-care professional. The client is alert and oriented and tells the RN he wants to leave the hospital now and not receive further treatment. Which of the following actions by the RN would be considered false imprisonment?

A. The RN tells the client he is not allowed to leave until the physician has released him.
B. The RN asks the client why he wishes to leave.
C. The RN asks the client to explain what he understands about his medical diagnosis.
D. The RN asks the client to sign an against medical advice discharge form.

Correct answer: A

Rationale: Verbal or physical detainment of a client who desires to leave the institution is false imprisonment.

3. Which of the following best describes the concept of patient-centered care?

A. Care that is directed solely by healthcare providers
B. Care that involves coordination among multiple healthcare providers
C. Care that prioritizes the patient's preferences, needs, and values
D. Care that strictly adheres to the latest clinical guidelines

Correct answer: C

Rationale: Patient-centered care is a healthcare approach that places the patient at the center of decision-making, emphasizing their preferences, needs, and values. This approach ensures that care is tailored to individual patients, taking into account their unique circumstances and actively involving them in their own care. Choice A is incorrect because patient-centered care focuses on the patient's needs rather than being solely directed by healthcare providers. Choice B is incorrect as involving multiple healthcare providers doesn't necessarily mean care is patient-centered; instead, it's about tailoring care to the patient's individual needs. Choice D is also incorrect as patient-centered care goes beyond just following clinical guidelines to encompass individual patient preferences and values.

4. Which nursing action can the nurse delegate to unlicensed assistive personnel (UAP) working in the diabetic clinic?

A. Measure the ankle-brachial index.
B. Check for changes in skin pigmentation.
C. Assess for unilateral or bilateral foot drop.
D. Ask the patient about symptoms of depression.

Correct answer: A

Rationale: The correct answer is A: Measure the ankle-brachial index. This task involves using a Doppler ultrasound device to assess blood flow, which can be safely delegated to UAP. Choices B, C, and D require a higher level of assessment and interpretation that should be performed by licensed nursing staff. Checking for changes in skin pigmentation (B) and assessing for foot drop (C) involve more complex assessments that require nursing judgment. Asking about symptoms of depression (D) involves a psychosocial assessment, which should be performed by licensed personnel qualified to address mental health concerns.

5. Which regulatory body mandates the provision of immunizations, especially for hepatitis B?

A. American Nurses Association (ANA)
B. Occupational Safety and Health Administration (OSHA)
C. Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
D. State board of nursing

Correct answer: B

Rationale: The correct answer is B - Occupational Safety and Health Administration (OSHA). OSHA mandates that the hepatitis B vaccine series must be offered to healthcare workers who are not immune to hepatitis. This requirement aims to protect healthcare workers from occupational exposure to bloodborne pathogens, including the hepatitis B virus. The American Nurses Association (ANA) (Choice A) is a professional organization for nurses, not a regulatory body. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (Choice C) focuses on accrediting healthcare organizations for quality and safety, not mandating immunizations. The State board of nursing (Choice D) is responsible for regulating nursing practice within a specific state, not mandating immunizations.