a client with diabetes mellitus presents with a blood sugar level of 320 mgdl what is the nurses initial action
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Nursing Elites

HESI RN

HESI RN Exit Exam 2023 Capstone

1. A client with diabetes mellitus presents with a blood sugar level of 320 mg/dL. What is the nurse's initial action?

Correct answer: A

Rationale: When a client with diabetes mellitus presents with a high blood sugar level of 320 mg/dL, the nurse's initial action should be to administer sliding scale insulin as prescribed. The priority is to bring down the elevated glucose level promptly to prevent further complications. Encouraging the client to drink fluids or providing a carbohydrate snack would not effectively address the elevated blood sugar level in this scenario. Assessing for signs of hypoglycemia is not appropriate as the client's blood sugar level is high, not low.

2. When conducting diet teaching for a client on a postoperative full liquid diet, which foods should the nurse encourage the client to eat?

Correct answer: A

Rationale: A full liquid diet includes foods that are liquid or will turn liquid at room temperature. Yogurt, milk, and pudding are appropriate choices as they align with the consistency requirements of a full liquid diet. Choices B, C, and D are incorrect. Tea, lentils, potato soup, ice cream, fruit smoothies, orange juice, mashed potatoes, and soft cheese are not typically part of a full liquid diet. These options either contain solid elements or are not in liquid form, which makes them unsuitable for a postoperative full liquid diet.

3. A client reports gastrointestinal upset after taking oral tetracycline. Which snack should the nurse recommend?

Correct answer: B

Rationale: The correct answer is B: Toast with jelly. Tetracycline can cause gastrointestinal upset when taken with dairy products. Yogurt with fruit (Choice A) contains dairy, which can worsen the gastrointestinal upset. Crackers with peanut butter (Choice C) and oatmeal with raisins (Choice D) are also not the best choices as they may not be gentle enough on the stomach. Toast with jelly is a simple snack that does not contain dairy and is less likely to exacerbate the gastrointestinal upset.

4. The nurse has received funding to design a health promotion project for African American women who are at risk for developing breast cancer. Which resource is most important in designing this program?

Correct answer: A

Rationale: The most important resource in designing a health promotion project for African American women at risk for breast cancer is the participation of community leaders in planning the program. Involving community leaders helps ensure that the program is culturally relevant, addresses the specific needs of the target population, and fosters trust and engagement. While the latest research on breast cancer risk factors, partnership with local healthcare providers, and health surveys of African American women are valuable resources, they are not as crucial as community involvement for tailoring the program effectively.

5. Which information is a priority for the RN to reinforce to an older client after intravenous pyelography?

Correct answer: D

Rationale: After intravenous pyelography, it is crucial for the client to measure urine output in the next day to monitor for any potential complications, such as kidney issues. Promptly notifying the healthcare provider in case of decreased urine output is essential for timely intervention. While rest and hydration are important post-procedure, monitoring urine output takes precedence due to its direct correlation with potential complications.

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