HESI RN
HESI Leadership and Management
1. When caring for a male client with diabetes insipidus, what does Nurse Juliet expect to administer?
- A. Vasopressin (Pitressin Synthetic)
- B. Furosemide (Lasix)
- C. Regular insulin
- D. 10% dextrose
Correct answer: A
Rationale: The correct answer is A: Vasopressin (Pitressin Synthetic). Vasopressin is the treatment of choice for diabetes insipidus as it replaces the deficient antidiuretic hormone. Furosemide (Lasix) (choice B) is a diuretic and would exacerbate fluid loss, making it inappropriate for diabetes insipidus. Regular insulin (choice C) is used for diabetes mellitus, not diabetes insipidus, which involves water balance rather than glucose regulation. 10% dextrose (choice D) is used to treat hypoglycemia, not diabetes insipidus.
2. The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the procedure?
- A. Experiences facial swelling after eating crab
- B. Reports left chest wall pain prior to the admission
- C. Verbalizes a fear of being in a confined space
- D. Drank a glass of water
Correct answer: A
Rationale: The correct answer is A. Allergy to shellfish can indicate a potential allergy to iodine, which is used in contrast dye for the procedure. This must be explored further to prevent an allergic reaction. Choice B is not directly related to the angioplasty procedure. Choice C pertains to claustrophobia, which can be addressed but is not directly related to the safety of the procedure. Choice D is a routine activity and does not pose a risk to the client during the procedure.
3. A client has a nursing diagnosis of 'spiritual distress.' What intervention is best for the nurse to implement when caring for this client?
- A. Use distraction techniques during times of spiritual stress and crisis.
- B. Reassure the client that their faith will be regained with time and support.
- C. Consult with the staff chaplain and request that the chaplain visit with the client.
- D. Use reflective listening techniques when the client expresses spiritual doubts.
Correct answer: D
Rationale: When a client is going through spiritual distress, employing reflective listening techniques is crucial. This method allows the client to voice their concerns and emotions, providing them with a supportive environment to explore their feelings. Options A and B do not directly address the client's spiritual distress and may undermine the client's feelings. While option C involves a chaplain, using reflective listening directly involves the nurse in addressing and supporting the client's spiritual concerns.
4. A nurse performing nasopharyngeal suctioning suddenly notes the presence of bloody secretions. What should the nurse do first?
- A. Continue suctioning to remove the blood
- B. Check the degree of suction being applied
- C. Encourage the client to cough out the bloody secretions
- D. Remove the suction catheter from the client’s nose and begin vigorous suctioning through the mouth
Correct answer: B
Rationale: The correct answer is to check the degree of suction being applied (Choice B). When bloody secretions are encountered during nasopharyngeal suctioning, it is crucial to assess the situation promptly. Checking the degree of suction being applied is the first step as excessive suction pressure may be causing trauma and bleeding. Adjusting the suction pressure may be necessary to prevent further harm. Continuing suctioning to remove the blood (Choice A) or performing vigorous suctioning through the mouth (Choice D) can lead to increased trauma and worsen bleeding. Encouraging the client to cough out the bloody secretions (Choice C) is not appropriate since the client undergoing suctioning is typically unable to expectorate secretions. Therefore, the priority is to check and adjust the suction settings to ensure safe and effective suctioning.
5. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation. Which assessment finding requires immediate intervention?
- A. Barrel-shaped chest
- B. Use of accessory muscles
- C. Oxygen saturation of 85%
- D. Inspiratory crackles
Correct answer: C
Rationale: An oxygen saturation of 85% is significantly low for a client with COPD and requires immediate intervention to prevent hypoxemia. Oxygen saturation below 90% indicates poor oxygenation and poses a risk of tissue hypoxia, making it a critical finding that needs prompt attention. Barrel-shaped chest and inspiratory crackles are commonly seen in clients with COPD and do not necessitate immediate intervention. The use of accessory muscles may indicate increased work of breathing but does not pose the same level of immediate threat as severe hypoxemia.