HESI RN
HESI RN Nursing Leadership and Management Exam 6
1. The client with type 2 DM is being instructed by the nurse about the importance of controlling blood glucose levels. The nurse should emphasize that uncontrolled blood glucose can lead to:
- A. Increased risk of heart disease and stroke.
- B. Improved wound healing.
- C. Reduced need for medication.
- D. Decreased risk of infection.
Correct answer: A
Rationale: Uncontrolled blood glucose levels are associated with an increased risk of cardiovascular complications, such as heart disease and stroke. High blood glucose levels can damage blood vessels over time, leading to atherosclerosis, which can increase the likelihood of heart disease and stroke. Improved wound healing (choice B) is not a consequence of uncontrolled blood glucose levels; in fact, high blood sugar levels can impair wound healing. Reduced need for medication (choice C) is inaccurate because uncontrolled blood glucose usually necessitates more medication to manage the condition. Decreased risk of infection (choice D) is also misleading as high blood glucose levels can compromise the immune system, making individuals more susceptible to infections.
2. The nurse is evaluating the health status of an older client. Which finding is most important for the nurse to report to the healthcare provider?
- A. Client reports decreased urine output
- B. Client reports loss of appetite
- C. Client reports pain in the lower back
- D. Client reports a persistent cough
Correct answer: C
Rationale: Pain in the lower back is a significant finding in an older client as it can indicate underlying issues such as kidney problems, spinal issues, or even aortic aneurysm. These conditions can be serious and require prompt medical attention. Decreased urine output (choice A) could indicate dehydration or kidney issues but is not as urgent as lower back pain. Loss of appetite (choice B) may be concerning but is not as critical as the potential life-threatening conditions associated with lower back pain. A persistent cough (choice D) is important to assess but is generally not as urgent as the potential serious implications of lower back pain in an older client.
3. Polyethylene glycol–electrolyte solution (GoLYTELY) is prescribed for a hospitalized client scheduled for a colonoscopy. The client begins to experience diarrhea after drinking the solution. Which action by the nurse is appropriate?
- A. Calling the physician
- B. Administering a cleansing enema
- C. Documenting the diarrhea in the medical record
- D. Giving intravenous replacement fluids in large amounts
Correct answer: C
Rationale: The correct action by the nurse in this situation is to document the diarrhea in the medical record. Polyethylene glycol–electrolyte solution (GoLYTELY) is a bowel evacuant used to cleanse the bowel before a colonoscopy. It is expected to cause mild diarrhea, which is a normal response to the medication. The diarrhea helps clear the bowel in preparation for the procedure. Calling the physician is not necessary unless there are complications. Administering a cleansing enema or giving intravenous replacement fluids in large amounts are not appropriate actions as they are not indicated for managing the expected diarrhea caused by GoLYTELY.
4. A client taking fexofenadine (Allegra) is scheduled for allergy skin testing and tells the nurse in the healthcare provider's office that a dose was taken this morning. The nurse determines that:
- A. The client should reschedule the appointment.
- B. A lower dose of allergen will need to be injected.
- C. A higher dose of allergen will need to be injected.
- D. The client should have the skin test read a day later than usual.
Correct answer: A
Rationale: Fexofenadine, an antihistamine, can cause false-negative readings in allergy skin testing and should be discontinued 3 days prior. Therefore, the client should reschedule the appointment to ensure accurate test results.
5. The client with a below-the-knee amputation is being taught about proper care of the residual limb. The most important point to emphasize would be
- A. Wrap the stump with an elastic bandage to prevent swelling
- B. Keep the skin on the stump clean and dry
- C. Use alcohol to cleanse the stump daily
- D. Apply moisturizing lotion to the stump daily
Correct answer: B
Rationale: The correct answer is B: Keep the skin on the stump clean and dry. This is crucial for preventing infection and promoting healing of the residual limb. Wrapping the stump with an elastic bandage can constrict blood flow and cause issues. Using alcohol to cleanse the stump daily can be too harsh and drying for the skin, leading to irritation. Applying moisturizing lotion daily is not as essential as keeping the skin clean and dry to prevent complications.