HESI RN
Leadership HESI Quizlet
1. The nurse is caring for a client with congestive heart failure. On assessment, the nurse notes that the client is dyspneic and that crackles are audible on auscultation. The nurse suspects excess fluid volume. What additional signs would the nurse expect to note in this client if excess fluid volume is present?
- A. Weight loss
- B. Flat neck and hand veins
- C. An increase in blood pressure
- D. A decreased central venous pressure (CVP)
Correct answer: C
Rationale: An increase in blood pressure is a common sign of fluid volume excess in clients with congestive heart failure due to the increased amount of fluid in the vascular system. Weight loss (Choice A) is not typically associated with fluid volume excess. Flat neck and hand veins (Choice B) are signs of fluid volume deficit, not excess. A decreased central venous pressure (CVP) (Choice D) is not expected in a client with fluid volume excess.
2. The client with type 1 diabetes mellitus is being educated by the nurse about the signs of hypoglycemia. Which of the following symptoms should the client be instructed to report immediately?
- A. Shakiness
- B. Sweating
- C. Confusion
- D. Increased thirst
Correct answer: C
Rationale: Confusion is a critical symptom of hypoglycemia that may indicate a more severe drop in blood glucose levels. Immediate reporting of confusion is crucial as it could progress rapidly to unconsciousness or seizures, necessitating prompt intervention. Shakiness and sweating are common early signs of hypoglycemia but may not require immediate intervention unless other severe symptoms present. Increased thirst is more indicative of hyperglycemia rather than hypoglycemia, and while it should be monitored, it is not a symptom requiring immediate reporting.
3. A male client with type 1 diabetes mellitus has a highly elevated glycosylated hemoglobin (Hb) test result. In discussing the result with the client, nurse Sharmaine would be most accurate in stating:
- A. The test needs to be repeated following a 12-hour fast.
- B. It appears you aren't following the prescribed diabetic diet.
- C. It tells us about your sugar control for the last 3 months.
- D. Your insulin regimen needs to be significantly altered.
Correct answer: C
Rationale: The correct answer is C. Glycosylated hemoglobin (HbA1c) reflects average blood glucose levels over the past 3 months. This test is used to assess long-term blood sugar control in individuals with diabetes. Choice A is incorrect because fasting is not required for an HbA1c test. Choice B is judgmental and not supported by the information provided. Choice D is not the most accurate statement to make based on the HbA1c result; adjusting insulin would depend on a more comprehensive assessment of the client's overall diabetes management.
4. A male client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?
- A. Infusing I.V. fluids rapidly as ordered
- B. Encouraging increased oral intake
- C. Restricting fluids
- D. Administering glucose-containing I.V. fluids as ordered
Correct answer: C
Rationale: The correct nursing intervention for a male client with SIADH is to restrict fluids. In SIADH, there is excess release of antidiuretic hormone (ADH), leading to water retention and dilutional hyponatremia. Restricting fluids helps prevent further dilutional hyponatremia by reducing water intake. Infusing I.V. fluids rapidly (choice A) would worsen the condition by adding more fluids, encouraging increased oral intake (choice B) is contraindicated as it adds more fluids, and administering glucose-containing I.V. fluids (choice D) is not a standard treatment for SIADH.
5. A male client with type 1 diabetes mellitus asks the nurse about taking an oral antidiabetic agent. Nurse Jack explains that these medications are only effective if the client:
- A. Prefers to take insulin orally.
- B. Has type 2 diabetes.
- C. Has type 1 diabetes.
- D. Is pregnant and has type 2 diabetes.
Correct answer: B
Rationale: Oral antidiabetic agents are specifically designed for type 2 diabetes mellitus. Type 1 diabetes requires insulin therapy as the primary treatment due to the absence of endogenous insulin production. Therefore, these medications are not effective for individuals with type 1 diabetes like the male client in this scenario. Choice A is incorrect as oral antidiabetic agents are not about preference but rather about treatment efficacy. Choice D is incorrect as being pregnant does not impact the effectiveness of oral antidiabetic agents; they are primarily indicated for type 2 diabetes.
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