a client with type 1 diabetes reports blurry vision what is the most important assessment the nurse should perform
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Nursing Elites

HESI RN

HESI RN Exit Exam 2024 Capstone

1. A client with type 1 diabetes reports blurry vision. What is the most important assessment the nurse should perform?

Correct answer: A

Rationale: Blurry vision in clients with type 1 diabetes may indicate hyperglycemia, which requires prompt assessment of recent blood glucose levels to determine the cause and appropriate intervention. Checking the client’s hemoglobin A1C level (Choice B) is useful for assessing long-term glucose control, not for immediate management of blurry vision. Monitoring blood pressure (Choice C) is important in diabetes care but is not the most crucial assessment when blurry vision is reported. Examining the client’s feet for signs of neuropathy (Choice D) is important in diabetic foot care but is not the priority when dealing with blurry vision.

2. A client is admitted with deep vein thrombosis (DVT) and is receiving heparin therapy. What is the most important laboratory value to monitor during heparin therapy?

Correct answer: C

Rationale: The activated partial thromboplastin time (aPTT) is the most important laboratory value to monitor during heparin therapy. It measures the intrinsic pathway of coagulation and is used to assess the effectiveness of heparin as an anticoagulant. Keeping the aPTT within the therapeutic range is crucial to prevent complications such as bleeding or clot formation. Prothrombin time (PT) and International normalized ratio (INR) are used to monitor warfarin therapy, not heparin. Platelet count is important to assess for thrombocytopenia, a potential side effect of heparin, but it is not the primary laboratory value to monitor the effectiveness of heparin therapy.

3. A client receiving total parenteral nutrition (TPN) reports nausea and dizziness. What action should the nurse take first?

Correct answer: B

Rationale: When a client receiving total parenteral nutrition (TPN) reports symptoms like nausea and dizziness, the first action the nurse should take is to check the client's vital signs and blood pressure. This assessment helps determine the client's overall stability and can provide crucial information to guide further interventions. Checking the blood glucose level (Choice A) may be relevant but is not the priority in this situation. Decreasing the infusion rate of TPN (Choice C) may be necessary but should be based on assessment findings. Administering antiemetic medication (Choice D) should not be the initial action without first assessing the client's vital signs.

4. A client is experiencing angina at rest. Which statement indicates a good understanding of the care required?

Correct answer: B

Rationale: The correct answer is B. Using nitroglycerin as needed, every 5 minutes, up to 3 doses, is the appropriate management for angina at rest. This helps dilate blood vessels, improving blood flow to the heart. Choice A is incorrect because chest pain that persists at rest should be addressed immediately, not waiting for 30 minutes. Choice C is incorrect as avoiding physical activity is not a recommended approach during an angina episode. Choice D is incorrect because nitroglycerin should be used during chest pain episodes, not as a preventive measure before physical activity.

5. A client presents with severe dehydration due to prolonged vomiting. What is the nurse's priority intervention?

Correct answer: B

Rationale: The correct answer is to assess the client's skin turgor and mucous membranes. When a client presents with severe dehydration, assessing skin turgor (elasticity of the skin) and mucous membranes (such as checking for dryness in the mouth) is crucial in determining the extent of dehydration. Encouraging the client to drink clear fluids (Choice A) may be important but assessing dehydration severity takes precedence. Monitoring vital signs (Choice C) is essential but assessing dehydration status comes first. Administering an antiemetic (Choice D) addresses vomiting but does not directly assess dehydration.

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