HESI RN
Evolve HESI Medical Surgical Practice Exam Quizlet
1. The client is being educated by the nurse on home blood glucose monitoring. Which of the following blood glucose measurements indicates hypoglycemia?
- A. 59 mg/dL (3.3 mmol/L)
- B. 75 mg/dL (4.2 mmol/L)
- C. 108 mg/dL (6 mmol/L)
- D. 119 mg/dL (6.6 mmol/L)
Correct answer: A
Rationale: A blood glucose level of 59 mg/dL (3.3 mmol/L) is considered hypoglycemia, which is an abnormally low blood sugar level. This level requires immediate attention as it can lead to symptoms such as confusion, shakiness, and even loss of consciousness if left untreated. Choices B, C, and D have blood glucose levels within the normal range or slightly higher, indicating euglycemia or normal blood sugar levels, and not hypoglycemia.
2. A 3-year-old child is brought to the clinic by the parents who are concerned that the child is not yet potty trained. What is the nurse’s best response?
- A. Most children are potty trained by this age, so you should not be concerned
- B. Every child develops at their own pace. Let’s discuss some strategies to help
- C. Your child may need to be evaluated for developmental delays
- D. It’s best to force your child to use the potty to encourage training
Correct answer: B
Rationale: The correct answer is B because it is important to acknowledge that children develop at different rates. By offering support and discussing strategies for potty training, the nurse can provide the necessary guidance without causing unnecessary concern or pressure on the parents. Choice A is incorrect because it dismisses the parents' concerns. Choice C is incorrect because jumping to the conclusion of developmental delays without further assessment or discussion can cause undue anxiety. Choice D is incorrect because forcing a child to use the potty can lead to resistance and negative associations with potty training.
3. Which nursing diagnosis is a priority for a 4-year-old child diagnosed with nephrotic syndrome?
- A. Impaired urinary elimination.
- B. Risk for infection.
- C. Fluid volume excess.
- D. Risk for impaired skin integrity.
Correct answer: C
Rationale: In a child with nephrotic syndrome, fluid volume excess is a priority nursing diagnosis due to the risk of edema and related complications. This patient may experience significant fluid retention, leading to edema, hypertension, and potential respiratory distress. Monitoring and managing fluid volume excess are crucial in preventing further complications and supporting the child's health during nephrotic syndrome. The other options are not the priority in this case. Impaired urinary elimination is not typically a primary concern in nephrotic syndrome. While infection is a risk due to compromised immunity, fluid volume excess poses a more immediate threat to the child's health. Risk for impaired skin integrity may be a concern secondary to edema, but addressing fluid volume excess takes precedence.
4. How should the caregiver instruct on caring for a 4-month-old with seborrheic dermatitis (cradle cap) when shampooing the child's hair?
- A. Use a soft brush and gently scrub the area.
- B. Avoid scrubbing the scalp until the scales disappear.
- C. Avoid washing the child's hair more than once a week.
- D. Use soap and water and avoid shampoos.
Correct answer: A
Rationale: When dealing with seborrheic dermatitis (cradle cap) in infants, it is essential to use a soft brush and gently scrub the affected area to help remove the scales. This process can aid in managing the condition and preventing further build-up. It is important to be gentle to avoid irritating the baby's delicate skin. Choice B is incorrect as gentle scrubbing with a soft brush can help in the removal of scales. Choice C is incorrect because regular but gentle washing is recommended to manage cradle cap. Choice D is incorrect as using specialized shampoos designed for cradle cap is usually recommended over soap and water.
5. A client with type 2 diabetes mellitus is prescribed metformin (Glucophage). Which instruction should the nurse include in the teaching plan?
- A. Take the medication with meals.
- B. Monitor for signs of hypoglycemia.
- C. Avoid alcohol while taking this medication.
- D. Take the medication at bedtime.
Correct answer: C
Rationale: Clients taking metformin (Glucophage) should avoid alcohol as it can increase the risk of lactic acidosis. Metformin should be taken with meals to reduce gastrointestinal upset. While hypoglycemia is less common with metformin compared to other diabetes medications, clients should still be aware of its symptoms.