HESI RN
HESI RN Nursing Leadership and Management Exam 5
1. Which of the following symptoms would be most concerning in a client with diabetes insipidus?
- A. Polydipsia
- B. Polyuria
- C. Nocturia
- D. Hypertension
Correct answer: D
Rationale: In a client with diabetes insipidus, excessive thirst (polydipsia) and excessive urination (polyuria) are expected symptoms due to the inability to concentrate urine, leading to dilute urine production. Nocturia, waking up at night to urinate, is also common. However, hypertension is not a typical symptom of diabetes insipidus. The correct answer is D because hypertension may indicate a complication such as dehydration or electrolyte imbalances, which would require further assessment in a client with diabetes insipidus.
2. After a spider bite on the lower extremity, a client is admitted to treat an infection that is spreading up the leg. Which admission assessment findings should the nurse report to the healthcare provider?
- A. Swollen lymph nodes in the groin
- B. Core body temperature of 100.5°F
- C. All of the above
- D. Elevated white blood cell count
Correct answer: C
Rationale: All of the above findings should be reported to the healthcare provider for prompt evaluation and treatment. Swollen lymph nodes in the groin indicate regional lymphatic involvement, a core body temperature of 100.5°F suggests a mild fever response, and an elevated white blood cell count indicates an ongoing infection process. These findings collectively point towards the spread of infection and require immediate attention to prevent further complications.
3. The nurse is caring for a client post appendectomy. The client has developed a fever, and the incision site is red and swollen. Which of these assessments is a priority for the nurse to perform?
- A. Check the client's blood pressure
- B. Assess the client's pain level
- C. Inspect the incision site
- D. Monitor the client's respiratory status
Correct answer: C
Rationale: Inspecting the incision site is a priority in this situation because the redness and swelling indicate a potential infection. This assessment helps the nurse determine the extent of infection and the appropriate intervention, such as administering antibiotics or notifying the healthcare provider. Checking the client's blood pressure (Choice A) may be important but is not the priority in this scenario where signs of infection are present. Assessing the client's pain level (Choice B) is also important but addressing the infection takes precedence. Monitoring the client's respiratory status (Choice D) is essential but not the priority when dealing with a localized infection at the incision site.
4. The healthcare provider is assessing a client who has returned from surgery. Which finding requires immediate intervention?
- A. Heart rate of 90 beats per minute.
- B. Oxygen saturation of 92%.
- C. Temperature of 99°F (37.2°C).
- D. Pain at the surgical site.
Correct answer: C
Rationale: A temperature of 99°F (37.2°C) in a postoperative client requires immediate intervention as it may indicate the presence of infection. Elevated temperature post-surgery can be a sign of surgical site infection or systemic infection, which can lead to serious complications if not addressed promptly. Monitoring and managing a fever in a postoperative client is crucial to prevent further complications. The other findings, such as a heart rate of 90 beats per minute, oxygen saturation of 92%, and pain at the surgical site, are common postoperative assessments that may not necessarily require immediate intervention unless they are significantly out of normal range or causing severe distress to the client.
5. The healthcare provider is assessing an older Caucasian male who has a history of peripheral vascular disease. The healthcare provider observes that the man's left great toe is black. The discoloration is probably a result of:
- A. Atrophy.
- B. Contraction.
- C. Gangrene.
- D. Rubor.
Correct answer: C
Rationale: Gangrene refers to dead, blackened tissue, often a result of chronic ischemia in clients with peripheral vascular disease. Atrophy (Choice A) is the wasting away or decrease in size of tissue or organ. Contraction (Choice B) refers to the shortening or tightening of a muscle or other body part. Rubor (Choice D) is a red discoloration of the skin, often associated with inflammation or poor circulation, but not typically presenting as blackening like gangrene.