an older client with type 1 diabetes arrives at the clinic with abdominal cramping vomiting lethargy and confusion what should the nurse implement fir
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Nursing Elites

HESI RN

HESI RN Exit Exam 2024 Quizlet Capstone

1. An older client with type 1 diabetes arrives at the clinic with abdominal cramping, vomiting, lethargy, and confusion. What should the nurse implement first?

Correct answer: A

Rationale: The correct answer is A: Start an IV infusion of normal saline. The client is showing signs of dehydration, such as abdominal cramping, vomiting, lethargy, and confusion, which can be exacerbated by hyperglycemia. Rehydration is the initial priority to address the fluid imbalance. Option B, obtaining a serum potassium level, though important in the management of diabetes, is not the immediate priority over rehydration. Option C, administering the client's usual dose of insulin, should only be done after addressing the dehydration and confirming the client's blood glucose levels. Option D, assessing the pupillary response to light, is not the most urgent intervention needed in this situation compared to rehydration to correct fluid imbalance.

2. A client with chronic kidney disease is prescribed a low-potassium diet. Which food should the nurse instruct the client to avoid?

Correct answer: C

Rationale: The correct answer is C: Bananas. Bananas are high in potassium and should be avoided in clients who are on a low-potassium diet due to chronic kidney disease. Foods like apples and white bread are low in potassium and are safer choices. Carrots are also low in potassium and do not need to be avoided in this case.

3. A client with hypertension is prescribed hydrochlorothiazide. What teaching should the nurse provide?

Correct answer: B

Rationale: The correct teaching for a client prescribed hydrochlorothiazide is to increase fluid intake to prevent dehydration. Hydrochlorothiazide is a diuretic that can lead to fluid loss and electrolyte imbalances, so adequate fluid intake is crucial. Choice A is incorrect because hydrochlorothiazide is typically taken in the morning to avoid nighttime urination. Choice C is incorrect as potassium-rich foods should not be avoided but monitored, as hydrochlorothiazide can cause potassium loss. Choice D is incorrect as potassium levels should be monitored regularly, but not necessarily weekly, unless indicated by the healthcare provider.

4. Why is it important for the healthcare provider to monitor blood pressure in clients receiving antipsychotic drugs?

Correct answer: A

Rationale: Corrected Question: Monitoring blood pressure in clients receiving antipsychotic drugs is crucial because orthostatic hypotension is a common side effect. Orthostatic hypotension can lead to a sudden drop in blood pressure upon standing, increasing the risk of falls and related injuries. Therefore, regular blood pressure monitoring helps healthcare providers detect and manage this potential side effect. Incorrect Choices Rationale: - Choice B is incorrect because while antipsychotic drugs can have various side effects, causing elevated blood pressure is not a common effect associated with them. - Choice C is unrelated to blood pressure monitoring in clients receiving antipsychotic drugs. Monitoring blood pressure in this context aims to detect and manage side effects of the medication, not to assess sodium intake. - Choice D is incorrect as monitoring blood pressure in clients receiving antipsychotic drugs is primarily aimed at detecting orthostatic hypotension, not as an indicator for instituting antiparkinsonian drugs.

5. Which of these clients, all in the terminal stage of cancer, is least appropriate to suggest the use of patient-controlled analgesia (PCA) with a pump?

Correct answer: D

Rationale: The correct answer is D. A preschooler with intermittent alertness episodes is not a suitable candidate for patient-controlled analgesia (PCA) due to their inability to effectively manage the system. In the context of terminal cancer, it is crucial for the patient to be able to utilize the PCA system appropriately to manage pain effectively. Preschoolers may not have the cognitive ability or understanding to operate a PCA pump compared to the other clients. Choices A, B, and C present clients with conditions that do not inherently impede their ability to use a PCA pump effectively.

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