a client with a history of diabetes mellitus is admitted with a blood glucose level of 600 mgdl and is unresponsive which intervention should the nurs
Logo

Nursing Elites

HESI RN

HESI RN Exit Exam

1. A client with a history of diabetes mellitus is admitted with a blood glucose level of 600 mg/dl and is unresponsive. Which intervention should the nurse implement first?

Correct answer: A

Rationale: Administering 50% dextrose IV push is the first priority in treating a blood glucose level of 600 mg/dl in a client who is unresponsive due to hyperglycemia. This intervention is crucial to rapidly raise the client's blood glucose levels and address the emergency situation. Administering insulin (Choice B) would further lower the blood glucose level, worsening the client's condition. Monitoring urine output (Choice C) and obtaining a blood glucose level (Choice D) are important assessments but are secondary to the immediate need to address the high blood glucose levels causing the client's unresponsiveness.

2. A male client with cancer who has lost 10 pounds during the last months tells the nurse that beef, chicken, and eggs, which used to be his favorite foods, now taste 'bitter'. He complains that he simply has no appetite. What action should the nurse implement?

Correct answer: A

Rationale: Offering alternative protein sources like dairy products and nuts can help maintain nutrition when the client finds certain foods unpalatable, as in this case where beef, chicken, and eggs taste 'bitter'. Encouraging smaller, more frequent meals may not address the issue of unpalatable foods. Offering nutritional supplements between meals may not specifically address the problem of protein intake. Discussing appetite stimulants should be considered after exploring less invasive options first.

3. A client with cirrhosis is admitted with jaundice and ascites. Which clinical finding is most concerning?

Correct answer: B

Rationale: Confusion and altered mental status are concerning in a client with cirrhosis as they may indicate hepatic encephalopathy, a serious complication that requires immediate intervention. Increased abdominal girth can be seen in ascites, yellowing of the skin is due to jaundice, and peripheral edema is associated with fluid retention in cirrhosis, but confusion and altered mental status are more closely linked to hepatic encephalopathy, which can progress rapidly and needs urgent attention.

4. The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver how many ml/hour?

Correct answer: C

Rationale: To calculate the infusion rate, convert 1 mg to 1,000 mcg (1 mg = 1,000 mcg) and then use the formula D/H x Q, where D is the desired dose, H is the dose on hand, and Q is the quantity of solution. In this case, it would be 300 mcg/hour / 1,000 mcg x 250 ml = 75 ml/hour. Therefore, the nurse should program the infusion pump to deliver 75 ml/hour. Choice A (50 ml/hour), Choice B (25 ml/hour), and Choice D (100 ml/hour) are incorrect as they do not correspond to the calculated rate of 75 ml/hour.

5. A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which clinical finding is most concerning to the nurse?

Correct answer: C

Rationale: The correct answer is C: Serum potassium of 3.2 mEq/L. A low serum potassium level in a client with DKA is concerning due to the risk of cardiac arrhythmias. Kussmaul respirations (choice A) are a compensatory mechanism for metabolic acidosis in DKA. A blood glucose level of 300 mg/dl (choice B) is elevated but expected in DKA. Positive urine ketones (choice D) are a classic finding in DKA and not as concerning as low serum potassium.

Similar Questions

The nurse observes an unlicensed assistive personnel (UAP) using an alcohol-based gel hand cleaner before performing catheter care. The UAP rubs both hands thoroughly for 2 minutes while standing at the bedside. Which action should the nurse take?
A client with end-stage renal disease (ESRD) is scheduled for hemodialysis. Which laboratory value should the nurse report to the healthcare provider immediately?
A client with a history of chronic alcoholism is admitted with confusion, ataxia, and diplopia. Which nursing intervention is a priority for this client?
An elderly female client with osteoarthritis reports increasing pain and stiffness in her right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of her symptoms?
A client with a history of angina pectoris is prescribed sublingual nitroglycerin. Which client statement indicates that further teaching is needed?

Access More Features

HESI RN Basic
$89/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses