DKA vs HHS — Quiz

Mr. Chen (54, male) in the emergency department has dka vs hhs. Shift assessment note: which findings require follow-up?

Select every finding below that is a cause for concern and requires follow-up.

• AA downward trend in oxygen saturation across two checks
• BA new report of worsening pain at the affected site
• CUrine output of 25 mL over the last hour
• DLung sounds unchanged from the client's documented baseline
• EA temperature that has remained in the normal range all shift

Unfolding case — Mr. Chen (54-year-old male), the emergency department, dka vs hhs. Hour 0: stable on admission orders. Hour 4: new cue suggests early deterioration. Hour 6: cue persists despite the first intervention. Which nursing actions are appropriate across this unfolding case?

Select all that apply.

• APerform a focused reassessment at each time point and compare with baseline
• BTitrate or implement prescribed interventions per orders as cues evolve
• CEscalate with SBAR when the cue persists past the first intervention
• DWait for the next scheduled assessment before acting on the new cue
• EDocument cues, actions, and the client's response with times

Two nursing actions for a 54-year-old male client (Mr. Chen) in the emergency department with dka vs hhs both appear correct. Which principle helps the nurse choose the best answer?

• AChoose the action that addresses the most urgent physiological threat (ABC/safety) first
• BChoose the action that takes the least time
• CChoose the action that requires the fewest supplies
• DChoose the action the client prefers

The nurse cares for a 29-year-old female client (Ms. Okafor) in a post-operative recovery bay admitted with dka vs hhs. Which assessment finding requires the nurse's immediate action?

• AA new, rapidly worsening change in airway, breathing, or circulation
• BA chronic finding documented since admission
• CA mild discomfort rated 3/10 that is unchanged
• DA laboratory value that is within the reference range

The nurse is planning care for a 29-year-old female client (Ms. Okafor) in a post-operative recovery bay with dka vs hhs. Which tasks are appropriate to delegate to unlicensed assistive personnel (UAP)?

Select all that apply.

• AMeasuring and recording vital signs on a stable client
• BAssisting with ambulation and activities of daily living
• CPerforming the initial head-to-toe assessment
• DRecording intake and output
• ETeaching the client about a new medication
• FReporting an observed change in condition to the nurse