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

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

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. A client with active tuberculosis asks why he must take four different medications. Which of the following responses should the nurse make?

Correct answer: B

Rationale: When treating tuberculosis, using a combination of multiple medications is crucial to reduce the risk of bacterial resistance. The use of four medications helps to target the bacteria from different angles, making it harder for them to develop resistance to the treatment. This approach is essential to ensure the effectiveness of the treatment regimen and to prevent the spread of drug-resistant strains of tuberculosis. Choices A, C, and D are incorrect because the primary reason for using multiple medications in tuberculosis treatment is to prevent the development of bacterial resistance, not to decrease the risk of allergic reactions, adverse reactions, or affecting the tuberculin skin test results.

3. A nurse is providing discharge teaching to a client who has a new prescription for enoxaparin. Which of the following instructions should the nurse include?

Correct answer: D

Rationale: The correct answer is to inject the medication into the abdomen. Enoxaparin should be administered subcutaneously into the abdomen for optimal absorption. Choice A is incorrect as there is no specific interaction between enoxaparin and spinach. Choice B is incorrect as massaging the injection site after administration is not recommended and can increase bruising. Choice C is incorrect as enoxaparin injections should not be administered into the deltoid muscle.

4. A woman who has been following a vegan diet may need ____ supplements.

Correct answer: B

Rationale: The correct answer is B: vitamin D and vitamin B12. Vegans may need to supplement vitamin D and B12 as these nutrients are mainly found in animal products. While choices A, C, and D are essential vitamins, they are not typically lacking in a vegan diet. Vitamin C can be obtained from various plant sources, vitamin A can be derived from beta-carotene in plants, and vitamin E and K are also found in plant-based foods. Niacin, although important, can be sourced from plant-based sources and is not a common deficiency in vegan diets.

5. A preschool-age boy presents to the outpatient clinic for a sore throat. In the child’s mind, which is the most likely cause for the sore throat?

Correct answer: D

Rationale: The correct answer is D. Preschool-age children often attribute illness to their actions, like yelling at a sibling or not following instructions. They may not understand medical causes such as exposure to infections like strep throat (choice A), dietary factors (choice B), or vitamin deficiencies (choice C). It is common for young children to connect symptoms to recent behaviors or events within their limited understanding.

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