HESI RN
HESI Quizlet Fundamentals
1. A client with a history of diabetes mellitus is admitted with a blood glucose level of 600 mg/dL. What type of insulin should the nurse prepare to administer to this client?
- A. Regular insulin
- B. NPH insulin
- C. Lispro insulin
- D. Glargine insulin
Correct answer: A
Rationale: In a client with a blood glucose level of 600 mg/dL, which indicates severe hyperglycemia or diabetic ketoacidosis, the nurse should prepare to administer regular insulin (A). Regular insulin has a rapid onset of action and is the preferred choice for immediate correction of high blood glucose levels. NPH insulin (B), lispro insulin (C), and glargine insulin (D) are not suitable for the rapid correction of severe hyperglycemia.
2. When taking a client's blood pressure, the healthcare professional is unable to distinguish the point at which the first sound was heard. What is the best action for the healthcare professional to take?
- A. Deflate the cuff completely and immediately reattempt the reading.
- B. Reinflate the cuff completely and leave it inflated for 90 to 110 seconds before taking the second reading.
- C. Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading.
- D. Document the exact level visualized on the sphygmomanometer where the first fluctuation was seen.
Correct answer: C
Rationale: The correct action when unable to distinguish the point of the first sound during blood pressure measurement is to deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. This allows blood flow to return to the extremity, ensuring a more accurate reading the second time. It is important to ensure that the cuff is fully deflated and the appropriate wait time is given to obtain an accurate blood pressure measurement.
3. A client with chronic kidney disease is receiving peritoneal dialysis. Which assessment finding should the nurse report to the healthcare provider immediately?
- A. The client's weight increases by 1 kg in 24 hours.
- B. The client's peritoneal effluent is cloudy.
- C. The client's blood pressure is 140/90 mm Hg.
- D. The client's peritoneal effluent is clear and pale yellow.
Correct answer: B
Rationale: Cloudy peritoneal effluent (B) is a sign of infection and should be reported to the healthcare provider immediately. It indicates the presence of peritonitis, a severe complication that requires prompt intervention. Weight gain (A) may indicate fluid overload but is not as urgent as a potential infection. Elevated blood pressure (C) is a common finding in clients with kidney disease and needs monitoring but does not require immediate reporting. Clear and pale yellow effluent (D) is a normal finding and does not raise immediate concerns.
4. An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. Which action should the nurse implement?
- A. Assist the client to walk to the bathroom and do not leave the client alone.
- B. Request that the UAP assist the client onto a bedpan.
- C. Ask if the client needs to have a bowel movement or void.
- D. Assess the client's bladder to determine if the client needs to urinate.
Correct answer: A
Rationale: Barbiturates cause central nervous system (CNS) depression, increasing the risk of falls. It is crucial for the nurse to assist the client to the bathroom to prevent potential injuries. Leaving the client alone may lead to accidents due to the effects of the medication. Monitoring and supporting the client during this activity is essential for ensuring safety and preventing falls.
5. A client with a history of myocardial infarction (MI) is admitted with chest pain. Which laboratory test should the nurse expect to be ordered to determine if the client is experiencing another MI?
- A. Troponin
- B. Myoglobin
- C. CK-MB
- D. C-reactive protein
Correct answer: A
Rationale: Troponin is the most specific and sensitive laboratory test for detecting myocardial infarction (MI). It is released when there is damage to the heart muscle, making it a valuable marker for diagnosing another MI. Myoglobin and CK-MB can also be elevated in MI, but troponin is preferred due to its higher specificity. C-reactive protein is a marker of inflammation and not specific to MI.
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