HESI RN
HESI RN Nursing Leadership and Management Exam 6
1. Which instruction about insulin administration should Nurse Kate give to a client?
- A. Always follow the same order when drawing up different insulins into the syringe.
- B. Shake the vials before withdrawing the insulin.
- C. Store unopened vials of insulin in the refrigerator at recommended temperatures.
- D. Discard the intermediate-acting insulin if it appears cloudy.
Correct answer: A
Rationale: The correct answer is A. Consistently following the same order when drawing up different insulins helps to prevent medication errors. Option B is incorrect because shaking insulin vials could cause bubbles to form, leading to inaccurate dosing. Option C is incorrect as insulin should be stored in the refrigerator, not the freezer, to maintain its effectiveness. Option D is incorrect because cloudy appearance in intermediate-acting insulin may indicate the presence of insulin crystals, which can affect its potency, but this does not necessarily mean it should be discarded without consulting a healthcare provider.
2. A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which clinical finding is most concerning?
- A. Serum glucose of 500 mg/dL
- B. Serum glucose of 600 mg/dL
- C. Serum potassium of 5.5 mEq/L
- D. Serum bicarbonate of 18 mEq/L
Correct answer: D
Rationale: A serum bicarbonate level of 18 mEq/L is most concerning in a client with DKA as it indicates metabolic acidosis, requiring immediate intervention. In DKA, the body produces excess ketones, leading to metabolic acidosis. A low serum bicarbonate level is a key indicator of this acid-base imbalance. Elevated serum glucose levels are expected in DKA but are managed through insulin therapy. Serum potassium levels can fluctuate in DKA due to insulin deficiency, but a value of 5.5 mEq/L is not as immediately concerning as metabolic acidosis. Therefore, the most critical finding in this scenario is the low serum bicarbonate level.
3. A client is taking levothyroxine (Synthroid). The nurse instructs the client to notify the health care provider (HCP) if which of the following occurs?
- A. Fatigue
- B. Tremors
- C. Cold intolerance
- D. Excessively dry skin
Correct answer: B
Rationale: Tremors are a sign of excessive doses of levothyroxine, indicating hyperthyroidism. It is important for the client to report tremors to the healthcare provider to prevent complications associated with overdosing on levothyroxine.
4. A female client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because she is being stalked. What action is most important for the nurse to take?
- A. Assure the client that she will be seen by a healthcare provider today.
- B. Recommend that the client speaks with a social worker.
- C. Ask the client if she feels comfortable sharing why she is being stalked.
- D. Offer the client a safe place to relax before interviewing her.
Correct answer: D
Rationale: The most important action for the nurse to take in this scenario is to offer the client a safe place to relax before interviewing her. The client's disheveled appearance and foul body odor suggest she may be in distress or facing challenging circumstances. By providing her with a safe and comfortable environment to relax, the nurse can help alleviate some of her distress and establish trust. This approach is crucial as the client is already feeling scared due to being stalked, indicating underlying mental health concerns. Assuring the client that she will be seen by a healthcare provider today (choice A) may not address her immediate need for safety and comfort. Recommending she speaks with a social worker (choice B) may be beneficial later but does not address the immediate need for a safe space. Asking the client if she feels comfortable sharing why she is being stalked (choice C) is not appropriate as the priority is ensuring her safety and comfort first.
5. The nurse assesses a client one hour after starting a transfusion of packed red blood cells and determines that there are no indications of a transfusion reaction. What instruction should the nurse provide the UAP who is working with the nurse?
- A. Encourage the client to increase fluid intake
- B. Document the absence of reaction
- C. Notify the nurse if the client develops a fever
- D. Continue to measure the client's vital signs every thirty minutes until the transfusion is complete
Correct answer: D
Rationale: Monitoring vital signs throughout a transfusion is critical, as reactions can occur later in the process. The UAP should continue to check vital signs regularly to ensure that any delayed reaction is promptly detected. Encouraging the client to increase fluid intake (Choice A) is not necessary at this point, as the focus should be on monitoring. Documenting the absence of a reaction (Choice B) is important but not as crucial as ongoing vital sign monitoring. Notifying the nurse if the client develops a fever (Choice C) is relevant but should not be the UAP's primary responsibility during the transfusion.