HESI RN
HESI RN Nursing Leadership and Management Exam 6
1. A client with DM is scheduled to have surgery. The nurse should plan to:
- A. Give the client a regular diet as ordered.
- B. Hold the client's insulin on the morning of surgery.
- C. Monitor the client's blood glucose level closely during the perioperative period.
- D. Have the client stop taking insulin 48 hours before surgery.
Correct answer: C
Rationale: The correct answer is to monitor the client's blood glucose level closely during the perioperative period. This is essential to ensure that the client's blood glucose levels remain within the target range and to prevent complications such as hypo- or hyperglycemia. Choices A, B, and D are incorrect because giving a regular diet as ordered, holding insulin on the morning of surgery, or stopping insulin 48 hours before surgery can lead to uncontrolled blood glucose levels, posing risks to the client's safety during the surgical procedure.
2. A healthcare professional is reading a physician's progress notes in the client's record and reads that the physician has documented 'insensible fluid loss of approximately 800 mL daily.' The healthcare professional understands that this type of fluid loss can occur through:
- A. The skin
- B. Urinary output
- C. Wound drainage
- D. The gastrointestinal tract
Correct answer: A
Rationale: Insensible fluid loss refers to the fluid lost from the body that is not easily measured, such as through sweating and respiration. The skin is a major contributor to insensible fluid loss due to evaporation of water through the skin. Choice B, urinary output, represents measurable fluid loss through urine excretion. Choice C, wound drainage, is a measurable form of fluid loss that occurs externally from a wound. Choice D, the gastrointestinal tract, primarily involves fluid loss through feces and is also a measurable form of output. Therefore, the correct answer is 'A: The skin,' as it is the main route for insensible fluid loss.
3. A 16-year-old male client who has been treated in the past for a seizure disorder is admitted to the hospital. Immediately after admission, he begins to have a grand mal seizure. Which action should the nurse take?
- A. Obtain assistance in holding him to prevent injury.
- B. Observe him carefully.
- C. Call a CODE.
- D. Place a padded tongue blade between the teeth.
Correct answer: B
Rationale: During a grand mal seizure, the priority action for the nurse is to ensure the safety of the client. Observing the client carefully allows the nurse to monitor the seizure activity, the client's breathing, and any signs of distress without interfering with the seizure process. Restraining the client or placing objects in the mouth can lead to injury and should be avoided. Calling a CODE is not appropriate for a seizure as it is a normal response to the client's condition.
4. A client who has a body mass index (BMI) of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurse recommend first?
- A. Plan low-carbohydrate and high-protein meals
- B. Engage in moderate physical activity for an hour daily
- C. Keep a record of food and drinks consumed daily
- D. Participate in a group exercise class 3 times a week
Correct answer: C
Rationale: A BMI of 30 indicates the patient is obese. The first step in a weight loss plan should be to keep a food journal to track calorie intake, which can help in meal planning and creating a workout routine. Choice (A) suggests a dietary approach, which is important but not the first step. Choice (B) recommends strenuous activity, which may not be suitable for everyone and is not the initial step. Choice (D) involves group exercise, which can be beneficial but is not the primary action to take at the beginning of a weight loss plan.
5. The nurse is teaching an 87-year-old client methods for maintaining regular bowel movements. The nurse would caution the client to AVOID
- A. Glycerin suppositories
- B. Fiber supplements
- C. Laxatives
- D. Stool softeners
Correct answer: C
Rationale: The correct answer is C: Laxatives. Laxatives can be harsh on elderly clients, leading to dependence and potential side effects. While fiber supplements (B) and stool softeners (D) are generally safe options to promote regular bowel movements, laxatives should be used cautiously in older adults due to their potential risks. Glycerin suppositories (A) can also be a safe and effective option for managing constipation in the elderly, but laxatives should be avoided unless deemed necessary by a healthcare provider.