HESI RN
HESI RN CAT Exam Quizlet
1. A client with diabetes mellitus reports feeling dizzy and has a blood glucose level of 50 mg/dl. What action should the nurse take first?
- A. Administer 1 mg of glucagon intramuscularly
- B. Provide 15 grams of carbohydrate
- C. Check the client's blood pressure
- D. Notify the healthcare provider
Correct answer: B
Rationale: Providing 15 grams of carbohydrate is the initial action to treat hypoglycemia. When a client with diabetes mellitus experiences symptoms of hypoglycemia, such as dizziness and with a blood glucose level of 50 mg/dl, the immediate priority is to raise their blood sugar levels quickly. Administering carbohydrates, such as fruit juice or glucose tablets, is the recommended first step to reverse hypoglycemia. Administering glucagon intramuscularly is usually reserved for severe hypoglycemia when the client is unconscious or unable to swallow. Checking the client's blood pressure is important but not the primary intervention for hypoglycemia. Notifying the healthcare provider can be done after the immediate management of hypoglycemia.
2. During a 30-second interval, the nurse counts six respirations, and the client coughs three times. In repeating the count for a second 30-second interval, the nurse counts eight respirations. What respiratory rate should the nurse document?
- A. 14
- B. 16
- C. 17
- D. 28
Correct answer: B
Rationale: The nurse should document a respiratory rate of 16. The second count of eight respirations in a 30-second interval is the most accurate as it was not interrupted by the client coughing. Therefore, this rate reflects the client's typical respiratory pattern and should be documented. Choices A, C, and D are incorrect as they do not consider the interruption caused by the client coughing during the first count, which could have affected the accuracy of the result. The second count of eight respirations provides a more reliable indication of the client's respiratory rate.
3. A client is prescribed allopurinol (Zyloprim) for chronic gout. Which instruction should the nurse include in the teaching plan?
- A. Take the medication with a full glass of water.
- B. Increase your intake of purine-rich foods.
- C. Stop taking the medication if you experience a gout attack.
- D. Take the medication with or without food.
Correct answer: A
Rationale: The correct instruction for a client prescribed allopurinol (Zyloprim) for chronic gout is to take the medication with a full glass of water. This helps prevent kidney stones which can be a side effect of the medication. It is important for the client to avoid purine-rich foods to help manage gout symptoms. They should continue taking the medication even during a gout attack as prescribed by the healthcare provider. Allopurinol can be taken with or without food, so there is no need to take it on an empty stomach. Therefore, option A is the correct choice. Options B, C, and D are incorrect as increasing purine-rich foods is not recommended, stopping the medication during a gout attack is not advised, and allopurinol can be taken with or without food.
4. A client with pneumonia is receiving oxygen via nasal cannula at 2 L/min. What assessment finding indicates the need for further intervention?
- A. The client reports feeling short of breath.
- B. The client's oxygen saturation is 92%.
- C. The client's respiratory rate is 20 breaths per minute.
- D. The client is unable to complete sentences without pausing.
Correct answer: D
Rationale: The correct answer is D because the inability to complete sentences without pausing indicates respiratory distress and the need for immediate intervention. This finding suggests an increased work of breathing and inadequate oxygenation. Choices A, B, and C are not as urgent as choice D. Feeling short of breath (choice A) is expected in pneumonia but does not necessarily indicate the need for immediate intervention. An oxygen saturation of 92% (choice B) is slightly below the normal range but may not require immediate intervention. A respiratory rate of 20 breaths per minute (choice C) is within the normal range and does not signify an urgent need for intervention.
5. A client with a history of peptic ulcer disease is admitted with severe abdominal pain. Which assessment finding requires immediate intervention?
- A. Epigastric tenderness.
- B. Bowel sounds are hypoactive.
- C. The client reports sudden, severe abdominal pain.
- D. Bowel sounds are hyperactive.
Correct answer: C
Rationale: The correct answer is C. Sudden, severe abdominal pain can indicate a perforated ulcer, which is a medical emergency requiring immediate intervention. Epigastric tenderness (choice A) may be expected in a client with peptic ulcer disease but does not necessarily require immediate intervention. Hypoactive bowel sounds (choice B) are concerning but not as urgent as sudden, severe abdominal pain. Hyperactive bowel sounds (choice D) are more indicative of conditions like gastroenteritis rather than a perforated ulcer, making it a less critical finding compared to sudden, severe abdominal pain.