a client with diabetes mellitus is admitted with a blood glucose level of 600 mgdl and is unresponsive which laboratory value is most concerning
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Nursing Elites

HESI RN

HESI RN Exit Exam 2023

1. A client with diabetes mellitus is admitted with a blood glucose level of 600 mg/dl and is unresponsive. Which laboratory value is most concerning?

Correct answer: C

Rationale: In a client with Hyperosmolar Hyperglycemic State (HHS), a serum pH of 7.30 is the most concerning value as it indicates acidosis, a life-threatening condition that requires immediate intervention. Choices A, B, and D are not the most concerning in this scenario. A low serum potassium level (Choice A) may be expected due to cellular shift in hyperglycemia, a serum glucose level of 200 mg/dl (Choice B) is not as concerning compared to the extremely high initial glucose level, and a serum sodium level of 135 mEq/L (Choice D) is within the normal range and not the immediate priority.

2. A client with hypertension receives a prescription for enalapril, an angiotensin-converting enzyme inhibitor (ACEI). Which instruction should the nurse include in the medication teaching plan?

Correct answer: B

Rationale: The correct instruction for the nurse to include in the medication teaching plan for a client receiving enalapril, an ACE inhibitor, is to 'Report increased bruising or bleeding.' ACE inhibitors can cause thrombocytopenia, which can lead to an increased risk of bruising and bleeding. Monitoring and reporting these symptoms promptly are essential to prevent complications. Choices A, C, and D are incorrect because increasing potassium-rich foods, stopping medication if a cough develops, and limiting intake of leafy green vegetables are not directly related to the common side effects or actions of ACE inhibitors.

3. A male client with cancer, who is receiving antineoplastic drugs, is admitted to the hospital. What findings are most often manifested in this condition?

Correct answer: A

Rationale: The correct answer is A: Ecchymosis and hematemesis. These findings are often manifested in a client receiving antineoplastic drugs due to their potential side effects, including increased bleeding tendencies. Choice B, weight loss, and alopecia are more commonly associated with the side effects of cancer itself rather than antineoplastic drugs. Choice C, weakness, and activity intolerance can be seen in cancer patients but are not specific to antineoplastic drug therapy. Choice D, sore throat, and fever are less likely to be directly related to antineoplastic drugs and are more often linked to infections or other conditions.

4. 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.

5. An older female client tells the nurse that her muscles have gradually been getting weaker over time. What is the best initial response by the nurse?

Correct answer: D

Rationale: The best initial response by the nurse should be to ask the client to describe the changes that have occurred. This open-ended question allows the nurse to gather valuable information directly from the client, aiding in assessing the situation accurately and formulating an appropriate care plan. Choice A is incorrect as assuming muscle weakness is an expected occurrence with aging without further assessment may overlook potential underlying issues. Choice B is premature as it jumps straight to physical examination without first gathering subjective data. Choice C is unnecessary at this point as reviewing diagnostic test results should come after initial assessment and data collection from the client.

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