a client with type 1 diabetes mellitus has influenza the nurse should instruct the client to
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Nursing Elites

HESI RN

HESI Medical Surgical Exam

1. A client with type 1 diabetes mellitus has influenza. The nurse should instruct the client to:

Correct answer: A

Rationale: During illness, individuals with type 1 diabetes mellitus may experience increased insulin requirements due to factors such as stress and the release of counterregulatory hormones. Increasing the frequency of self-monitoring, as stated in choice A, is crucial to closely monitor and adjust insulin doses as needed. Choice B, reducing food intake to alleviate nausea, is incorrect as it may lead to hypoglycemia and does not address the increased insulin needs during illness. Choice C, discontinuing the insulin dose if unable to eat, is dangerous as it can result in uncontrolled hyperglycemia. Choice D, taking the normal dose of insulin, may not be sufficient during illness when insulin requirements are likely elevated.

2. In a client with heart failure presenting bilateral +4 edema of the right ankle extending up to midcalf while sitting with legs dependent, what is the priority goal?

Correct answer: A

Rationale: The priority goal in this scenario is to decrease venous congestion. By elevating the legs above the heart level, venous return is improved, reducing congestion in the lower extremities. This intervention helps decrease swelling and prevents complications such as impaired tissue perfusion. Maintaining normal respirations and body temperature are important aspects of care but are secondary to addressing the immediate issue of venous congestion. Preventing injury to lower extremities is also essential but takes precedence after managing the venous congestion to prevent further complications.

3. A 20-year-old female client calls the nurse to report a lump she found in her breast. Which response is the best for the nurse to provide?

Correct answer: B

Rationale: The nurse advising the client to come in provides the best response because it addresses the client's anxiety most effectively and encourages prompt and immediate action for a potential problem.

4. The charge nurse of the medical-surgical unit is making staff assignments. Which staff member should be assigned to a client with chronic kidney disease who is exhibiting a low-grade fever and a pericardial friction rub?

Correct answer: C

Rationale: The client is exhibiting symptoms of pericarditis, which can occur with chronic kidney disease. Continuity of care is crucial to assess subtle changes in clients' conditions. Therefore, the registered nurse (RN) who previously cared for this client should be assigned again. Float nurses may lack knowledge of the unit and its clients, potentially leading to oversight of critical details. The licensed practical nurse, while experienced, may not possess the advanced assessment skills and education level of an RN to effectively evaluate and manage pericarditis in this client.

5. During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving. What action should the nurse take first?

Correct answer: B

Rationale: The most common reason for inadequate lung aeration during CPR is the incorrect positioning of the head, leading to airway obstruction. Therefore, the initial action should be to reposition the head to open the airway properly and attempt to ventilate again. Using a laryngoscope to check for foreign bodies in the airway (Choice A) is not the first step and could delay crucial interventions. Turning the client to the side and administering back blows (Choice C) is not indicated in this scenario as the focus is on ventilating the lungs. Performing a finger sweep of the mouth (Choice D) is not recommended as it may push obstructions further into the airway during CPR.

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