HESI RN
Leadership HESI
1. During a physical assessment of a client with type 2 DM, a nurse notes the following findings: fasting blood glucose of 120 mg/dl, temperature of 101°F, pulse 88 bpm, respirations 22/min, and BP 140/84 mmHg. Which finding should concern the nurse the most?
- A. Pulse
- B. BP
- C. Respiration
- D. Temperature
Correct answer: D
Rationale: The correct answer is 'Temperature.' A temperature of 101°F indicates a fever, which can be a sign of infection. In individuals with diabetes, infections can lead to significant complications and affect blood glucose control. Monitoring and addressing infections promptly are crucial in individuals with diabetes to prevent worsening of their condition. Choice A, 'Pulse,' is within the normal range (60-100 bpm) and does not indicate an immediate concern. Choice B, 'BP,' while slightly elevated, is not as acutely concerning as an elevated temperature in this scenario. Choice C, 'Respiration,' falls within the normal range (12-20 breaths/min) and is not the most concerning finding among the options provided.
2. The nurse is caring for a patient who is receiving oral potassium chloride supplements. The nurse notes that the patient has a heart rate of 120 beats per minute and has had a urine output of 200 mL in the past 12 hours. The patient reports abdominal cramping. Which action will the nurse take?
- A. Contact the provider to request an order for serum electrolytes.
- B. Encourage the patient to consume less fluids.
- C. Report symptoms of hyperkalemia to the provider.
- D. Request an order to increase the patient’s potassium dose.
Correct answer: A
Rationale: Oliguria, tachycardia, and abdominal cramping are signs of hyperkalemia, so the nurse should request an order for serum electrolytes to assess the patient's potassium levels. Encouraging the patient to consume less fluids would not address the underlying issue of potential hyperkalemia. Reporting symptoms of hyperkalemia to the provider is not as proactive as directly requesting serum electrolytes. Increasing the patient's potassium dose would worsen hyperkalemia, which is already suspected based on the symptoms presented.
3. A patient taking trimethoprim-sulfamethoxazole (TMP-SMX) to treat a urinary tract infection complains of a sore throat. The nurse will contact the provider to request an order for which laboratory test(s)?
- A. Complete blood count with differential
- B. Throat culture
- C. Urinalysis
- D. Coagulation studies
Correct answer: A
Rationale: When a patient taking trimethoprim-sulfamethoxazole (TMP-SMX) for a urinary tract infection presents with a sore throat, the nurse should request a complete blood count with differential. TMP-SMX can cause life-threatening adverse effects such as agranulocytosis, a condition characterized by a low white blood cell count, which can manifest as a sore throat. Ordering a complete blood count with differential helps assess the patient's white blood cell count to detect any potential serious adverse effects. Throat culture (Choice B) is not indicated unless there are specific signs of a throat infection. Urinalysis (Choice C) is not relevant for assessing a sore throat. Coagulation studies (Choice D) are not typically indicated for a sore throat symptom.
4. During a prenatal visit, the nurse discusses with a client the effects of smoking on the fetus. When compared with nonsmokers, mothers who smoke during pregnancy tend to produce infants who have
- A. lower Apgar scores.
- B. lower birth weights.
- C. respiratory distress.
- D. a higher rate of congenital anomalies.
Correct answer: B
Rationale: Smoking during pregnancy is associated with intrauterine growth restriction, leading to lower birth weights. This occurs due to the harmful effects of smoking on fetal development, which can result in reduced nutrient and oxygen supply to the fetus, impacting its overall growth and leading to lower birth weights. Choices A, C, and D are incorrect as smoking during pregnancy primarily affects fetal growth and development, leading to lower birth weights rather than lower Apgar scores, respiratory distress, or a higher rate of congenital anomalies.
5. What is the role of the progesterone hormone?
- A. Stimulates the development of the nipple and duct system in the breast.
- B. Stimulates the storage of milk.
- C. Stimulates the secretion of relaxin.
- D. Stimulates the development of glandular tissue in the breast.
Correct answer: A
Rationale: The correct answer is A. Progesterone hormone's role includes stimulating the development of the nipple and duct system in the breast. This hormone is crucial for preparing the breast for potential pregnancy by promoting the growth of structures necessary for milk production. Choices B, C, and D are incorrect because progesterone primarily focuses on preparing the breast for lactation rather than directly stimulating milk storage, relaxin secretion, or glandular tissue development.