HESI RN
HESI RN CAT Exam Quizlet
1. The nurse is preparing to administer the 0800 dose of 20 units of Humulin R to an 8-year-old girl diagnosed with Type 1 diabetes. The mother comments that her daughter is a very picky eater and many times does not eat meals. Which intervention should the nurse implement first?
- A. Administer the 20 Units of Humulin R subcutaneously as prescribed
- B. Ask the girl if she will be eating her breakfast this morning
- C. Discuss changing the insulin prescription to Lispro with the healthcare provider
- D. Explain to the mother the importance of eating the scheduled meals
Correct answer: B
Rationale: The correct answer is to ask the girl if she will be eating her breakfast this morning. This is important to determine if the child will be consuming food, which is crucial information before administering insulin. If the child does not plan to eat, administering the full dose of insulin may lead to hypoglycemia. Choice A is incorrect as administering the insulin without knowing if the child will eat can be dangerous. Choice C is not the first intervention because the immediate concern is the child's meal intake. Choice D, while important, is not the first step in this situation.
2. The client has had a femoral-popliteal bypass surgery 6 hours ago. Which assessment provides the most accurate information about the client's postoperative status?
- A. Radial pulse.
- B. Femoral pulse.
- C. Apical pulse.
- D. Dorsalis pedis pulse.
Correct answer: D
Rationale: Assessing the dorsalis pedis pulse is crucial after a femoral-popliteal bypass surgery to determine adequate circulation distal to the surgical site. A strong dorsalis pedis pulse indicates sufficient blood flow to the foot, which is essential for monitoring postoperative status. The radial pulse (A) is not the most relevant assessment as it does not provide direct information on circulation in the lower extremities. The femoral pulse (B) may not accurately reflect circulation distal to the surgical site. The apical pulse (C) is used primarily to assess the heartbeat and cardiac function, not circulation in the lower extremities.
3. The nurse is caring for a newly admitted patient who has severe gastroenteritis. The patient’s electrolytes reveal a serum sodium level of 140 mEq/L and a serum potassium level of 3.5 mEq/L. The nurse receives an order for intravenous 5% dextrose and normal saline with 20 mEq/L potassium chloride to infuse at 125 mL per hour. Which action is necessary prior to administering this fluid?
- A. Evaluate the patient’s urine output.
- B. Contact the provider to order arterial blood gases.
- C. Request an order for an initial potassium bolus.
- D. Suggest a diet low in sodium and potassium.
Correct answer: A
Rationale: Prior to administering IV fluids containing potassium, it is crucial to evaluate the patient's urine output. If the urine output is less than 25 mL/hr or 600 mL/day, there is a risk of potassium accumulation. Patients with low urine output should not receive IV potassium to prevent potential complications. Contacting the provider for arterial blood gases is unnecessary in this scenario as it does not directly relate to the administration of IV fluids with potassium. Administering potassium as a bolus is not recommended due to potential adverse effects. While dietary considerations are important, suggesting a low-sodium and low-potassium diet is not the immediate action required before administering IV fluids with potassium chloride.
4. The client with Addison's disease is receiving education on managing the condition. Which of the following instructions should be included?
- A. Increase your sodium intake during periods of stress.
- B. Avoid all types of exercise.
- C. Decrease your fluid intake to prevent fluid overload.
- D. Stop corticosteroid therapy once symptoms improve.
Correct answer: A
Rationale: The correct instruction to include for a client with Addison's disease is to increase sodium intake during periods of stress. In Addison's disease, there is a deficiency of aldosterone leading to sodium loss. Increasing sodium intake helps to compensate for this loss and prevent complications. Choice B is incorrect as exercise is beneficial for overall health but should be done in moderation. Choice C is incorrect as fluid intake should be adequate to prevent dehydration since clients with Addison's disease are prone to electrolyte imbalances. Choice D is incorrect as corticosteroid therapy is essential for managing Addison's disease and should not be discontinued abruptly without medical guidance.
5. A client with type 1 diabetes is found unconscious with a blood glucose of 40 mg/dL. What is the nurse's priority intervention?
- A. Administer a 50% dextrose bolus intravenously.
- B. Administer glucagon intramuscularly.
- C. Provide oral glucose gel.
- D. Recheck the blood glucose level in 15 minutes.
Correct answer: A
Rationale: The correct answer is to administer a 50% dextrose bolus intravenously. In unconscious clients with hypoglycemia, IV dextrose rapidly raises the blood glucose level. Glucagon would be a slower option and is typically used if IV access is unavailable. Oral glucose gel is not appropriate for an unconscious client as it requires swallowing and may cause aspiration. Rechecking the blood glucose level in 15 minutes delays immediate treatment and could lead to further deterioration.