HESI RN
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1. The nurse is preparing to administer NPH insulin to a client. The nurse should administer the insulin at which site for the best absorption?
- A. The deltoid muscle
- B. The anterior thigh
- C. The abdomen
- D. The gluteal muscle
Correct answer: C
Rationale: The abdomen is the preferred site for insulin injection due to its consistent absorption rate. Insulin injected into the abdomen is absorbed more consistently and predictably than in other sites. The deltoid muscle and the anterior thigh are not recommended for insulin injections due to inconsistent absorption rates. The gluteal muscle is avoided for insulin injections due to the risk of hitting the sciatic nerve or causing discomfort to the client.
2. Which of the following clinical findings would be most concerning in a client with hypothyroidism?
- A. Bradycardia
- B. Dry skin
- C. Constipation
- D. Depression
Correct answer: A
Rationale: Bradycardia in a client with hypothyroidism is the most concerning finding as it may indicate severe hypothyroidism, leading to decreased heart rate. Bradycardia can be a sign of myxedema coma, a life-threatening condition that requires immediate medical attention. Dry skin, constipation, and depression are common symptoms associated with hypothyroidism but are not as acutely concerning as bradycardia.
3. A client with diabetes insipidus is being treated with desmopressin. The nurse should monitor for which of the following side effects?
- A. Hyponatremia
- B. Hypernatremia
- C. Hypokalemia
- D. Hypercalcemia
Correct answer: A
Rationale: The correct answer is A: Hyponatremia. Desmopressin, a medication used in diabetes insipidus, can cause water retention by increasing water reabsorption in the kidneys. This excess water retention can lead to dilutional hyponatremia, where sodium levels in the body become too low. Monitoring for hyponatremia is crucial to prevent complications such as neurological symptoms. Choices B, C, and D are incorrect because desmopressin is not known to cause hypernatremia, hypokalemia, or hypercalcemia.
4. The client has syndrome of inappropriate antidiuretic hormone (SIADH). Which intervention is most appropriate?
- A. Encourage increased fluid intake
- B. Administer hypertonic saline
- C. Monitor for signs of dehydration
- D. Restrict oral fluids
Correct answer: D
Rationale: The correct intervention for a client with syndrome of inappropriate antidiuretic hormone (SIADH) is to restrict oral fluids. This is because SIADH leads to excessive production of antidiuretic hormone, causing water retention and dilutional hyponatremia. By restricting oral fluids, the nurse helps prevent further water retention and imbalance of electrolytes. Encouraging increased fluid intake (Choice A) would exacerbate the condition by further increasing fluid retention. Administering hypertonic saline (Choice B) is not the primary treatment for SIADH, as it may worsen the imbalance. Monitoring for signs of dehydration (Choice C) is not appropriate since SIADH leads to water retention, not dehydration.
5. A patient with acute congestive heart failure is receiving high doses of a diuretic. On assessment, the nurse notes flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. Suspecting hyponatremia, what additional signs would the nurse expect to note in this patient if hyponatremia were present?
- A. Dry skin
- B. Decreased urinary output
- C. Hyperactive bowel sounds
- D. Increased specific gravity of the urine
Correct answer: C
Rationale: In a patient with hyponatremia, hyperactive bowel sounds are expected due to increased gastrointestinal motility. Dry skin (Choice A) is not a typical sign of hyponatremia. Decreased urinary output (Choice B) is more commonly associated with conditions like dehydration or renal issues, not specifically hyponatremia. Increased specific gravity of the urine (Choice D) is a sign of concentrated urine, which is not a characteristic finding in hyponatremia.
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