HESI RN
Adult Health 2 HESI Quizlet
1. When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient’s food tray?
- A. Grape juice
- B. Milk carton
- C. Mixed green salad
- D. Fried chicken breast
Correct answer: B
Rationale: The correct answer is B: Milk carton. Foods high in phosphate, like milk and other dairy products, are restricted on low-phosphate diets to manage renal failure. Green, leafy vegetables, high-fat foods, and fruits/juices are not high in phosphate and are not restricted. Therefore, grape juice, mixed green salad, and fried chicken breast do not need to be removed from the patient's food tray.
2. A client with DM is scheduled for surgery. The nurse should plan to:
- A. Monitor the client's blood glucose level closely during the perioperative period.
- B. Give the client a regular diet as ordered.
- C. Have the client stop taking insulin 48 hours before surgery.
- D. Hold the client's insulin on the morning of surgery.
Correct answer: A
Rationale: The correct answer is to monitor the client's blood glucose level closely during the perioperative period. For a client with diabetes mellitus (DM) scheduled for surgery, it is essential to closely monitor blood glucose levels to prevent hypo- or hyperglycemia. Choice B is incorrect because giving the client a regular diet as ordered may not address the specific needs related to managing blood glucose levels in the perioperative period. Choice C is incorrect as abruptly stopping insulin 48 hours before surgery can lead to uncontrolled blood sugar levels, which is not recommended. Choice D is incorrect because holding the client's insulin on the morning of surgery can also disrupt blood sugar control, potentially leading to complications during the perioperative period.
3. A client with type 2 diabetes mellitus arrives at the clinic reporting episodes of weakness and palpitations. Which finding should the nurse identify may indicate an emerging situation?
- A. History of hypertension
- B. Fingertips feel numb
- C. Reduced deep tendon reflexes
- D. Elevated fasting blood glucose level
Correct answer: B
Rationale: Numb fingertips may suggest neuropathy, a common complication of diabetes that may indicate a worsening condition. Episodes of weakness and palpitations, combined with neuropathy symptoms, could also suggest hypoglycemia or poor glycemic control, requiring further investigation. The other choices are less likely to be directly related to the client's current symptoms. While a history of hypertension is a common comorbidity in clients with diabetes, it may not directly explain the reported weakness and palpitations. Reduced deep tendon reflexes are more indicative of certain neurological conditions rather than acute emerging situations related to the client's current symptoms. An elevated fasting blood glucose level is expected in a client with type 2 diabetes and may not be the primary indicator of an emerging situation in this context.
4. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy. Which assessment finding indicates that the client's oxygenation is improving?
- A. Pulse oximetry reading of 94%
- B. Heart rate increases from 80 to 90 beats per minute
- C. Respiratory rate increases from 16 to 20 breaths per minute
- D. Client reports increased energy levels
Correct answer: A
Rationale: A pulse oximetry reading of 94% indicates adequate oxygenation. Monitoring oxygen saturation is the most objective way to assess the effectiveness of oxygen therapy. Choices B, C, and D do not directly reflect the client's oxygenation status. An increase in heart rate or respiratory rate may indicate increased work of breathing or stress on the body. The client reporting increased energy levels is subjective and may not directly correlate with improved oxygenation.
5. During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate first?
- A. Respiratory apnea of 30 seconds
- B. Oxygen saturation rate of 88%
- C. Eight premature ventricular beats every minute
- D. Disconnected monitor signal for the last 6 minutes.
Correct answer: A
Rationale: The correct answer is A: Respiratory apnea of 30 seconds. Respiratory apnea indicates a cessation of breathing, which is a life-threatening emergency requiring immediate intervention. Priority should be given to assessing and managing airway, breathing, and circulation. Option B, oxygen saturation rate of 88%, can indicate hypoxemia, but addressing the lack of breathing takes precedence. Option C, eight premature ventricular beats every minute, and option D, a disconnected monitor signal, are important but do not pose an immediate threat to the client's life compared to respiratory apnea.