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ANCC Medical-Surgical Nursing Exam Prep

Category - Medical-Surgical Nursing Practice Test

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Which of the following evaluation data would best lead the nurse to conclude that the client with hyperglycemic hyperosmolar nonketotic coma (HHNK) has demonstrated improvement during the first 24 hours?
  1. Alert and oriented, balanced intake and output, and moist mucous membranes
  2. Intake equals output, denies pain and shortness of breath
  3. Alert and oriented, blood and urine without ketones, and no orthostatic BP
  4. Respirations easy and even, eats 50 to 75 percent of meals, and vital signs stable
Explanation
Answer - A - Alert and oriented, balanced intake and output, and moist mucous membranes. HHNK results from hyperglycemia, causing excessive loss of water and retention of glucose that leads to dehydration, hypernatremia, and hypokalemia. Symptoms are dry, tenting skin, dry mucous membranes, altered level of consciousness, and hyperthermia. Ketones are not present in HHNK; thus, monitoring for ketones is inappropriate (Choice C). Choices B and D do not address the primary problems that occur with HHNK.
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