the client has received iv solutions for three 3 days through a 20 gauge iv catheter placed in the left cephalic vein on morning rounds the nurse note
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HESI RN

HESI RN Nursing Leadership and Management Exam 5

1. The client has received IV solutions for three (3) days through a 20-gauge IV catheter placed in the left cephalic vein. On morning rounds, the nurse notes the IV site is tender to palpation and a red streak has formed. Which action should the nurse implement first?

Correct answer: B

Rationale: The first action should be to discontinue the intravenous line to prevent further complications such as infection or thrombophlebitis. Starting a new IV in the right hand is not the priority as addressing the current issue is important. Completing an incident record can be done after addressing the immediate concern of the IV site. Placing a warm washcloth over the site does not address the red streak and tenderness, which may indicate an infection that requires discontinuation of the IV line.

2. Dr. Kennedy prescribes glipizide (Glucotrol), an oral antidiabetic agent, for a male client with type 2 diabetes mellitus who has been having trouble controlling the blood glucose level through diet and exercise. Which medication instruction should the nurse provide?

Correct answer: A

Rationale: Glipizide should be taken 30 minutes before meals to maximize its glucose-lowering effect.

3. Early this morning, a female client had a subtotal thyroidectomy. During evening rounds, Nurse Tina assesses the client, who now has nausea, a temperature of 105°F (40.5°C), tachycardia, and extreme restlessness. What is the most likely cause of these signs?

Correct answer: B

Rationale: The correct answer is B: Thyroid crisis. Thyroid crisis, also known as thyroid storm, is a life-threatening condition that can occur after a thyroidectomy. Symptoms include high fever, tachycardia, extreme restlessness, and other signs of severe hyperthyroidism. Diabetic ketoacidosis (choice A) is a complication of diabetes characterized by hyperglycemia, ketosis, and acidosis, not typically seen post-thyroidectomy. Hypoglycemia (choice C) is low blood sugar levels and would not present with the symptoms described. Tetany (choice D) is a condition of involuntary muscle spasms due to low calcium levels and is not directly related to the symptoms observed in this scenario.

4. Skillful communication is one behavior of an effective leader. Which of the following describes an effective method of communication?

Correct answer: A

Rationale: Meeting with a new nurse to discuss progress and areas for improvement is an effective communication method.

5. The client with type 2 diabetes mellitus is being educated about lifestyle modifications. Which of the following recommendations is appropriate?

Correct answer: C

Rationale: The correct answer is to increase physical activity to help control blood glucose levels. Physical activity is essential in managing type 2 diabetes mellitus as it helps improve insulin sensitivity, control weight, and regulate blood sugar levels. Avoiding all forms of physical exercise (Choice A) is incorrect as exercise plays a crucial role in diabetes management. While limiting carbohydrate intake (Choice B) can be beneficial, setting a strict limit of less than 30 grams per day is too restrictive and may not be suitable for everyone. Consuming a high-protein, low-fat diet (Choice D) is generally a healthy choice, but it is not the primary lifestyle modification recommended for managing type 2 diabetes mellitus.

Similar Questions

The client has been diagnosed with primary aldosteronism. Which of the following clinical findings would the nurse expect?
A client with type 2 diabetes mellitus is being discharged after receiving initial treatment. What should the nurse emphasize as a crucial instruction?
The nurse is caring for a client with hypothyroidism. Which of the following clinical findings should the nurse expect?
The client with hyperparathyroidism is being taught about dietary management. Which of the following foods should the client avoid?
Why is glucose an important molecule in a cell?

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