HESI RN
Leadership HESI
1. Capillary glucose monitoring is being performed every 4 hours for a female client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which she receives 8 U of regular insulin. Nurse Vince should expect the dose's:
- A. Onset to be at 2 p.m. and its peak to be at 3 p.m.
- B. Onset to be at 2:15 p.m. and its peak to be at 3 p.m.
- C. Onset to be at 2:30 p.m. and its peak to be at 4 p.m.
- D. Onset to be at 4 p.m. and its peak to be at 6 p.m.
Correct answer: C
Rationale: The correct answer is C. Regular insulin typically has an onset of action within 30 minutes and peaks 2-4 hours after administration. Given that the insulin was administered at 2 p.m., the onset of action can be expected around 2:30 p.m., and the peak effect would occur between 4-6 p.m. Choice A is incorrect as the onset and peak are too close together for regular insulin. Choice B is incorrect because the onset time is too soon after administration. Choice D is incorrect as the onset time is too delayed for regular insulin.
2. A client has undergone renal angiography via the right femoral artery. The nurse determines that the client is experiencing a complication of the procedure upon noting:
- A. Urine output of 40 mL/hr
- B. Blood pressure of 118/76 mm Hg
- C. Respiratory rate of 18 breaths/min
- D. Pallor and coolness of the right leg
Correct answer: D
Rationale: Pallor and coolness of the right leg indicate a potential vascular complication following renal angiography, such as hemorrhage, thrombosis, or embolism. These signs suggest impaired circulation in the affected limb. Urine output, blood pressure, and respiratory rate are not typically associated with complications of renal angiography. Complications of this procedure mainly involve allergic reactions to the dye, dye-induced renal damage, and various vascular issues.
3. What forms the vaginal lining?
- A. Squamous epithelium
- B. Stratified epithelium
- C. Vascular connective tissue
- D. Muscle coat
Correct answer: A
Rationale: The vaginal lining is primarily formed by squamous epithelium. Squamous epithelium is the correct answer because it is the type of epithelium that lines the vaginal canal. Stratified epithelium consists of multiple layers and is not the primary type found in the vaginal lining. Vascular connective tissue and muscle coat are not the main components of the vaginal lining, making them incorrect choices.
4. A young male client is admitted to rehabilitation following a right above-knee amputation (AKA) and reports aching in his right foot. Which intervention is most important for the nurse to implement?
- A. Encourage discussion about feelings of limb loss.
- B. Administer a prescription for gabapentin.
- C. Teach the client how to wrap the stump with an elastic bandage.
- D. Offer assistance to move to a quiet room to relax.
Correct answer: B
Rationale: The correct answer is B: Administer a prescription for gabapentin. Gabapentin is used to treat phantom limb pain, which is common after amputations. Encouraging discussion about feelings of limb loss (choice A) is important for emotional support but does not address the physical pain. Teaching the client how to wrap the stump with an elastic bandage (choice C) is not indicated for aching in the 'right foot' as described. Offering assistance to move to a quiet room to relax (choice D) may provide comfort but does not address the underlying issue of phantom limb pain.
5. Which laboratory test should the nurse monitor to determine the effectiveness of heparin therapy for a client with deep vein thrombosis?
- A. Platelet count
- B. Prothrombin time (PT)
- C. Activated partial thromboplastin time (aPTT)
- D. Hemoglobin and hematocrit
Correct answer: C
Rationale: The activated partial thromboplastin time (aPTT) is the specific laboratory test used to monitor the effectiveness of heparin therapy in patients with deep vein thrombosis. It measures the time it takes for blood to clot and is crucial in assessing the therapeutic range of heparin. Platelet count, prothrombin time (PT), and hemoglobin and hematocrit levels are important parameters in assessing coagulation and blood status but do not directly indicate the effectiveness of heparin therapy.