which nursing diagnosis has the highest priority when planning care for a client in cardiogenic shock
Logo

Nursing Elites

HESI RN

HESI RN CAT Exam Quizlet

1. Which nursing diagnosis has the highest priority when planning care for a client in cardiogenic shock?

Correct answer: D

Rationale: In cardiogenic shock, the priority nursing diagnosis is Ineffective Tissue Perfusion. This diagnosis indicates that the client is not receiving adequate oxygenated blood to tissues, putting vital organs at risk. Addressing ineffective tissue perfusion is crucial to prevent organ damage and ensure the client's survival. The other options, such as 'Risk for imbalanced body temperature,' 'Excess fluid volume,' and 'Fatigue,' are important but secondary to the immediate threat of inadequate tissue perfusion in cardiogenic shock.

2. A nurse is planning care for a client who is newly diagnosed with diabetes mellitus. Which instruction should the nurse include in this client’s teaching plan?

Correct answer: C

Rationale: Rotating insulin injection sites prevents lipodystrophy and ensures proper insulin absorption.

3. A 3-year-old boy is brought to the emergency center with dysphagia, drooling, a fever of 102°F, and stridor. Which intervention should the nurse implement first?

Correct answer: A

Rationale: In a 3-year-old boy presenting with dysphagia, drooling, fever, and stridor, the priority intervention should be to place the child in a mist tent. This intervention helps alleviate respiratory distress, providing immediate relief. Options B, C, and D are not as urgent as ensuring the child's airway is managed effectively. Obtaining a sputum culture, preparing for a tracheostomy, and examining the oropharynx can be done after stabilizing the child's respiratory status.

4. A client with type 2 diabetes mellitus is admitted for antibiotic treatment of a leg ulcer. Which signs and symptoms, indicative of hyperosmolar hyperglycemic nonketotic syndrome (HHNS), should the nurse report to the healthcare provider? (Select one that doesn't apply.)

Correct answer: C

Rationale: The correct answer is C, 'Presence of uremic frost.' Increased heart rate, visual disturbances, and decreased mentation are all signs and symptoms indicative of hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Uremic frost, however, is not associated with HHNS but is a clinical finding seen in severe cases of chronic kidney disease. Therefore, the nurse should report the presence of uremic frost to the healthcare provider as a separate concern from HHNS.

5. An angry client screams at the emergency department triage nurse, 'I've been waiting here for two hours! You and the staff are incompetent.' What is the best response for the nurse to make?

Correct answer: D

Rationale: The correct response for the nurse is to choose option D, 'I understand you are frustrated with the wait time.' This response acknowledges the client's emotions, shows empathy, and validates their feelings of frustration. Option A justifies the situation but does not address the client's emotional state. Option B is unfair to other patients and may not be based on urgency. Option C focuses on the nurse's actions rather than addressing the client's emotions, making it less effective than option D.

Similar Questions

A healthcare provider is assessing a client who is receiving treatment for dehydration. Which assessment finding indicates that the client is responding to the treatment?
A client who is HIV positive and taking lamivudine (Epivir) calls the clinic to report a cough and fever. What action should the nurse implement?
A postoperative client returns to the nursing unit following a ureter lithotomy via a flank incision. Which potential nursing problem has the highest priority when planning nursing care for this client?
A client with diabetes mellitus reports feeling dizzy and has a blood glucose level of 50 mg/dl. What action should the nurse take first?
When evaluating the preoperative teaching of a client scheduled for arthroscopic anterior cruciate ligament repair, which statement by the client indicates that the teaching was effective?

Access More Features

HESI RN Basic
$89/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses