a nurse is teaching a client with type 2 diabetes about the importance of foot care which statement by the client indicates a need for further teachin

HESI RN

HESI 799 RN Exit Exam

1. A nurse is teaching a client with type 2 diabetes about the importance of foot care. Which statement by the client indicates a need for further teaching?

A. I should check my feet every day for cuts or blisters.
B. I need to moisturize my feet daily, especially between my toes.
C. I should wear comfortable shoes that fit well.
D. I should avoid walking barefoot, even indoors.

Correct answer: B

Rationale: The correct answer is B. Moisturizing between the toes can create a moist environment that fosters fungal infections. Checking the feet daily for cuts or blisters (choice A) is correct in diabetes management to prevent complications. Wearing comfortable shoes that fit well (choice C) and avoiding walking barefoot (choice D) are also essential in preventing foot ulcers and injuries in diabetic patients.

2. A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which clinical finding is most concerning to the nurse?

A. Kussmaul respirations
B. Blood glucose level of 300 mg/dl
C. Serum potassium of 3.2 mEq/L
D. Positive urine ketones

Correct answer: C

Rationale: The correct answer is C: Serum potassium of 3.2 mEq/L. A low serum potassium level in a client with DKA is concerning due to the risk of cardiac arrhythmias. Kussmaul respirations (choice A) are a compensatory mechanism for metabolic acidosis in DKA. A blood glucose level of 300 mg/dl (choice B) is elevated but expected in DKA. Positive urine ketones (choice D) are a classic finding in DKA and not as concerning as low serum potassium.

3. An adult male who lives alone is brought to the Emergency Department by his daughter. He is unresponsive, with minimal respiratory effort, and his pupils are fixed and dilated. At the daughter's request, the client is intubated and mechanically ventilated. Which nursing intervention has the highest priority?

A. Offer to notify the client's minister of his condition.
B. Determine if the client has an executed living will.
C. Provide the family with information about palliative care.
D. Explore the possibility of organ donation with the family.

Correct answer: B

Rationale: The highest priority nursing intervention in this scenario is to determine if the client has an executed living will. A living will provides guidance on the client's preferences for medical care in situations where they cannot communicate. This information is crucial in guiding the care team on how to proceed with treatment. Options A, C, and D, though important in certain circumstances, are not the highest priority in this situation where immediate decisions regarding the client's care need to be made.

4. The nurse is caring for a client following a myelogram. Which assessment finding should the nurse report to the healthcare provider immediately?

A. Complaint of headaches and stiff neck.
B. Complaint of dizziness and nausea.
C. Increased pain at the puncture site.
D. Mild redness around the puncture site.

Correct answer: A

Rationale: The correct answer is A: Complaint of headaches and stiff neck. Headaches and stiff neck following a myelogram may indicate a cerebrospinal fluid (CSF) leak or other complications that require prompt medical attention. Reporting this finding immediately is crucial to prevent further complications. Choices B, C, and D are incorrect because while they may warrant monitoring and intervention, they are not as indicative of a potentially serious complication as the symptoms described in choice A.

5. A male client with impaired renal function who takes ibuprofen daily for chronic arthritis is admitted with gastrointestinal (GI) bleeding. After administering IV fluids and a blood transfusion, his blood pressure is 100/70, and his renal output is 20 ml/hour. Which intervention should the nurse include in care?

A. Maintain the client NPO during the diuresis phase.
B. Evaluate daily serial renal laboratory studies for progressive elevations.
C. Observe the urine character for sedimentation and cloudy appearance.
D. Monitor for onset of polyuria greater than 150ml/hour.

Correct answer: B

Rationale: Evaluating daily renal laboratory studies is crucial in this scenario. The client has impaired renal function, recent GI bleeding, and is at risk for further kidney damage due to ibuprofen use. Monitoring renal labs helps assess kidney function and detect any progressive elevations, guiding further interventions. Option A is not directly related to renal function monitoring. Option C focuses more on urine appearance than renal function assessment. Option D mentions polyuria, which is excessive urine output, but the question describes a client with reduced renal output.