an adolescent who was diagnosed with diabetes mellitus type 1 at the age of 9 is admitted to the hospital in diabetic ketoacidosis which occurrence is
Logo

Nursing Elites

HESI RN

HESI 799 RN Exit Exam Capstone

1. An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9 is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of ketoacidosis?

Correct answer: A

Rationale: The correct answer is A. Infections, like a cold and ear infection, increase the body's metabolic needs and insulin resistance, making diabetic ketoacidosis (DKA) more likely. While missing insulin doses or not following dietary restrictions can trigger DKA, an illness is the most common precipitating factor in pediatric Type 1 diabetes. Option B is less likely as missing insulin can lead to hyperglycemia but might not be the immediate cause of ketoacidosis. Option C can contribute to DKA over time, but the acute trigger is usually an illness. Option D, overexertion during exercise, is less likely to cause DKA compared to an infection.

2. The nurse is caring for a client with fluid overload. The most reliable indicator of fluid volume status is

Correct answer: C

Rationale: Daily weight is the most reliable indicator of fluid volume status as it reflects changes in body fluid balance accurately. Body weight alone can fluctuate due to various factors, including food intake and bowel movements, which may not accurately represent fluid status. Intake and output provide information on fluid balance over time but may not reflect immediate changes. Skin turgor is a physical assessment finding that indicates hydration status, not overall fluid volume status.

3. After a spider bite on the lower extremity, a client is admitted to treat an infection that is spreading up the leg. Which admission assessment findings should the nurse report to the healthcare provider?

Correct answer: C

Rationale: All of the above findings should be reported to the healthcare provider for prompt evaluation and treatment. Swollen lymph nodes in the groin indicate regional lymphatic involvement, a core body temperature of 100.5°F suggests a mild fever response, and an elevated white blood cell count indicates an ongoing infection process. These findings collectively point towards the spread of infection and require immediate attention to prevent further complications.

4. A client who recently underwent a tracheostomy is being prepared for discharge to home. Which instructions are most important for the nurse to include in the discharge plan?

Correct answer: B

Rationale: The correct answer is B: Teach tracheal suctioning techniques. Tracheal suctioning is crucial for maintaining a clear airway in clients with a tracheostomy. Without proper suctioning, secretions can accumulate and cause airway obstruction or respiratory infections. Educating the client on how to perform suctioning safely is a priority for discharge planning. Choices A, C, and D are important aspects of tracheostomy care, but teaching tracheal suctioning techniques takes precedence due to its direct impact on airway patency and preventing complications.

5. A client with pancreatitis reports severe pain after eating fatty foods. What intervention should the nurse implement?

Correct answer: B

Rationale: In pancreatitis, pain after consuming fatty foods is common due to increased pancreatic stimulation. Administering antispasmodics is the appropriate intervention as it can help reduce the pain by decreasing pancreatic enzyme secretion. Encouraging the client to eat small, low-fat meals (Choice A) is beneficial in managing pancreatitis symptoms but does not directly address the acute pain. Instructing the client to avoid eating until the pain subsides (Choice C) may lead to nutritional deficiencies and is not the best approach. Increasing high-protein foods intake (Choice D) is not recommended as it can put additional strain on the pancreas.

Similar Questions

The nurse administers an antibiotic for a respiratory tract infection. To evaluate the medication's effectiveness, which laboratory values should the nurse monitor?
A client with congestive heart failure is prescribed digoxin. What symptom indicates digoxin toxicity?
The nurse is caring for a client with a suspected myocardial infarction (MI). Which laboratory test result is most indicative of a recent MI?
The nurse is preparing a teaching plan for a client diagnosed with asthma. The primary purpose of the plan is to
A 4-year-old child is returned to the room following a tonsillectomy and adenoidectomy. Which of the following assessments would require the nurse's immediate attention?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses