HESI RN
HESI Leadership and Management
1. For a male client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume?
- A. Cool, clammy skin
- B. Distended neck veins
- C. Increased urine osmolarity
- D. Decreased serum sodium level
Correct answer: C
Rationale: Increased urine osmolarity is the best assessment finding supporting a nursing diagnosis of Deficient fluid volume in a male client with hyperglycemia. In hyperglycemia, there is increased glucose in the blood, which leads to osmotic diuresis. This results in the excretion of large amounts of urine that is concentrated (high osmolarity), leading to dehydration and fluid volume deficit. Cool, clammy skin (Choice A) is more indicative of poor perfusion, distended neck veins (Choice B) are associated with fluid volume excess, and decreased serum sodium level (Choice D) could be a result of dilutional hyponatremia due to fluid overload rather than deficient fluid volume.
2. A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor while the patient is receiving this infusion?
- A. Lung sounds
- B. Urinary output
- C. Peripheral pulses
- D. Peripheral edema
Correct answer: A
Rationale: The correct answer is A: Lung sounds. Hypertonic solutions like 3% NaCl can cause water retention, leading to fluid excess. Monitoring lung sounds is crucial as crackles may indicate pulmonary edema, a serious manifestation of fluid excess. While monitoring urinary output, peripheral pulses, and peripheral edema are also important when administering hypertonic solutions, they do not provide immediate clues to acute respiratory or cardiac decompensation like lung sounds.
3. Which two items react during cellular respiration?
- A. Glucose and water
- B. Carbon dioxide and water
- C. Carbon dioxide and oxygen
- D. Glucose and oxygen
Correct answer: D
Rationale: The correct answer is D: Glucose and oxygen. During cellular respiration, glucose and oxygen react in the presence of enzymes to produce carbon dioxide, water, and energy in the form of ATP. Choice A (Glucose and water) is incorrect because water is a product of cellular respiration, not a reactant. Choice B (Carbon dioxide and water) is incorrect as carbon dioxide is produced during cellular respiration, not a reactant. Choice C (Carbon dioxide and oxygen) is incorrect because oxygen is a reactant in cellular respiration, not a product.
4. A client who gave birth 48 hours ago has decided to bottle-feed the infant. The nurse observes that both breasts were swollen, warm, and tender on palpation during the assessment. Which instruction should the nurse provide?
- A. Take warm showers to reduce swelling
- B. Wear a tight-fitting bra for support
- C. Apply ice to the breasts for comfort
- D. Express milk manually to relieve discomfort
Correct answer: C
Rationale: The correct answer is to advise the client to apply ice to the breasts for comfort. Applying ice can help reduce swelling and discomfort associated with engorgement in a woman who is not breastfeeding. Expressing milk manually would stimulate further milk production, which is not desired in this case. Wearing a tight bra could increase discomfort by putting pressure on the engorged breasts. Warm showers may actually increase swelling due to the vasodilation effect of heat.
5. 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.