HESI RN
HESI RN Nursing Leadership and Management Exam 6
1. The nurse and an unlicensed nursing assistant are caring for a group of clients. Which nursing intervention should the nurse perform?
- A. Measure the client's output from the indwelling catheter.
- B. Record the client's intake and output on the I & O sheet.
- C. Instruct the client on appropriate fluid restrictions.
- D. Provide water for a client diagnosed with diabetes insipidus.
Correct answer: C
Rationale: Instructing the client on appropriate fluid restrictions is a nursing intervention that requires professional judgment and should be performed by the nurse. In this scenario, the nurse should provide education regarding fluid restrictions based on the client's individual needs. Measuring the client's output from the indwelling catheter (choice A) and recording intake and output (choice B) can be tasks delegated to the unlicensed nursing assistant. Providing water for a client diagnosed with diabetes insipidus (choice D) is not appropriate as these clients often require careful fluid management to prevent complications.
2. Which of the following options identifies the products of cell respiration?
- A. Water, carbon dioxide, and oxygen
- B. Glucose and oxygen
- C. Water, carbon dioxide, and adenosine triphosphate (ATP)
- D. Water, glucose, and oxygen
Correct answer: C
Rationale: The correct answer is C: 'Water, carbon dioxide, and adenosine triphosphate (ATP).' During cellular respiration, glucose is broken down in the presence of oxygen to produce water, carbon dioxide, and ATP. Choice A is incorrect as oxygen is not a product of cell respiration but a reactant. Choice B is incorrect as it lists glucose and oxygen, which are actually reactants in the process. Choice D is incorrect as glucose is not a product of cell respiration but a substrate that is broken down to release energy.
3. A young adult male is admitted to the emergency department with diabetic ketoacidosis (DKA). His pH is 7.25, HCO3 is 12 mEq/L, and blood glucose is 310 mg/dl. Which action should the nurse implement?
- A. Infuse sodium chloride 0.9% (normal saline)
- B. Prepare an emergency dose of glucagon
- C. Determine the last time the client ate
- D. Check urine for ketone bodies with a dipstick
Correct answer: A
Rationale: In DKA, restoring fluid balance with sodium chloride is a priority to address the dehydration and electrolyte imbalances present in this condition. Choice B, preparing an emergency dose of glucagon, is incorrect because DKA is characterized by insulin deficiency, not glucagon deficiency. Choice C, determining the last time the client ate, is not the immediate priority in managing DKA. Choice D, checking urine for ketone bodies with a dipstick, may help confirm the diagnosis of DKA but is not the most critical intervention at this time.
4. During a home visit, an elderly female client who had a brain attack three months ago and can now ambulate with a quad cane is assessed by the nurse. Which assessment finding has the greatest implications for this client's care?
- A. The husband, who is the caregiver, begins to weep when the nurse asks how he is doing.
- B. The client tells the nurse that she does not have much of an appetite today.
- C. The nurse notes that there are numerous scatter rugs throughout the house.
- D. The client's pulse rate is 10 beats higher than it was at the last visit one week ago.
Correct answer: C
Rationale: The presence of numerous scatter rugs throughout the house poses a significant safety hazard to the client who is ambulating with a quad cane. These rugs increase the risk of tripping and falling, making it the most critical finding that needs immediate attention to prevent potential injuries and ensure the client's safety during ambulation.
5. A 2-year-old girl is brought to the clinic by her 17-year-old mother. When the nurse observes that the child is drinking sweetened soda from her bottle, what information should the nurse discuss with this mother?
- A. A 2-year-old should be speaking in 2-word phrases
- B. Dental caries is associated with drinking soda
- C. Drinking soda is related to childhood obesity
- D. Toddlers should be sleeping 10 hours a night
Correct answer: B
Rationale: Dental caries are a common concern when children consume sweetened sodas regularly.