HESI RN
HESI Fundamentals Quizlet
1. A female client’s significant other has been at her bedside providing reassurances and support for the past 3 days, as desired by the client. The client’s estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement?
- A. Obtain a prescription from the healthcare provider regarding visitation privileges
- B. Request a consultation with the ethics committee for resolution of the situation
- C. Encourage the client to speak with her husband regarding his disruptive behavior
- D. Communicate the client’s wishes to all members of the multidisciplinary team
Correct answer: B
Rationale: In a situation where a client's estranged husband demands to restrict the visitation of the significant other, it is essential to prioritize the client's wishes while addressing the conflict. Requesting a consultation with the ethics committee is appropriate as it allows for a comprehensive and impartial resolution, ensuring the client's autonomy and well-being are upheld. Option A is incorrect because visitation privileges are not solely determined by a healthcare provider's prescription in this scenario. Option C may not be appropriate as it puts the client in a potentially uncomfortable or unsafe position. Option D, while important, does not directly address the conflict between the estranged husband and the significant other.
2. The nurse is caring for a client with diabetic ketoacidosis (DKA). Which intervention is most important?
- A. Administer insulin as prescribed.
- B. Monitor the client's urine output.
- C. Assess the client's level of consciousness.
- D. Obtain an arterial blood gas (ABG) sample.
Correct answer: A
Rationale: Administering insulin is the most crucial intervention in managing diabetic ketoacidosis. Insulin helps reduce blood glucose levels and correct metabolic acidosis, which are the primary issues in DKA. Monitoring urine output (Choice B) is important but not as critical as administering insulin. Assessing the client's level of consciousness (Choice C) is essential but does not directly address the underlying cause of DKA. Obtaining an arterial blood gas sample (Choice D) can provide valuable information but is not as urgent as administering insulin to address the immediate metabolic imbalance.
3. The healthcare provider is assessing a client with suspected diabetes insipidus. Which of the following clinical manifestations would support this diagnosis?
- A. Polyuria and polydipsia
- B. Hypertension and bradycardia
- C. Weight gain and edema
- D. Oliguria and thirst
Correct answer: A
Rationale: Polyuria (excessive urination) and polydipsia (excessive thirst) are classic clinical manifestations of diabetes insipidus. In this condition, there is a deficiency of antidiuretic hormone, leading to the inability of the kidneys to concentrate urine effectively, resulting in increased urine output (polyuria) and consequent thirst (polydipsia). Hypertension and bradycardia (Choice B) are not typical findings in diabetes insipidus. Weight gain and edema (Choice C) are more indicative of conditions such as heart failure or nephrotic syndrome. Oliguria (decreased urine output) and thirst (Choice D) are contradictory symptoms to what is seen in diabetes insipidus.
4. The healthcare provider is reviewing the serum laboratory findings for a 5-day-old infant with congenital adrenal hyperplasia. Which laboratory result should be reported to the healthcare provider immediately?
- A. Bilirubin of 1.5 mg/dl.
- B. Glucose of 80 mg/dl.
- C. Potassium of 4.5 mEq/L.
- D. Sodium of 119 mEq/L.
Correct answer: D
Rationale: Low sodium levels in congenital adrenal hyperplasia can indicate salt-wasting crisis, which is a life-threatening emergency requiring immediate medical attention. Monitoring sodium levels is crucial to prevent complications such as dehydration and shock in these patients.
5. When planning a scoliosis screening clinic, which age group should be included?
- A. early adolescent girls
- B. late adolescent boys
- C. 7-10 year old boys
- D. preschoolers of both genders
Correct answer: A
Rationale: The correct answer is early adolescent girls. Scoliosis is most commonly diagnosed during early adolescence, with girls being more affected than boys. Including early adolescent girls in the screening clinic aligns with the age group that is at higher risk for scoliosis. Late adolescent boys (choice B) are less likely to develop scoliosis compared to early adolescent girls. 7-10 year old boys (choice C) are typically younger than the age group where scoliosis is commonly diagnosed. Preschoolers of both genders (choice D) are too young for scoliosis screening as the condition usually manifests during adolescence.