ATI RN
Pediatric HESI Test Bank Questions
Question 1 of 5
Nurse Karen is caring for a client with chronic renal failure. Which is a correct intervention for hyperkalemia?
Correct Answer: B
Rationale: Hyperkalemia is a common complication in patients with chronic renal failure due to the kidneys' inability to excrete potassium efficiently. The correct intervention for hyperkalemia includes assessing the patient for muscle weakness, diarrhea, and ECG changes. Muscle weakness is a common symptom of hyperkalemia due to its effects on neuromuscular function. Diarrhea can lead to potassium loss from the gastrointestinal tract, helping to lower potassium levels. ECG changes are essential to monitor in hyperkalemia as high potassium levels can result in life-threatening cardiac arrhythmias. By identifying these signs and symptoms early, appropriate interventions can be initiated promptly, such as administering medications to lower potassium levels or adjusting the patient's diet to limit potassium intake.
Question 2 of 5
Following a transsphenoidal hypophysectomy, the nurse should assess the client care fully for which of the following conditions?
Correct Answer: A
Rationale: Following a transsphenoidal hypophysectomy, the nurse should assess the client carefully for hypocortisolism, also known as adrenal insufficiency. This is because the procedure involves removing the pituitary gland, which plays a critical role in regulating cortisol production by the adrenal glands. Without proper cortisol production, the client may develop symptoms such as weakness, fatigue, low blood pressure, weight loss, and nausea. Monitoring for signs of hypocortisolism is crucial for prompt detection and intervention to prevent adrenal crisis, which can be life-threatening. Hyperglycemia, hypoglycemia, and hypercalcemia are not typically direct concerns following a transsphenoidal hypophysectomy.
Question 3 of 5
The nurse administered neutral protamine Hagedorn (NPH) insulin to a diabetic client at 7am. At what time would the nurse expect the client to be at most risk for a hypoglycemic reaction?
Correct Answer: D
Rationale: NPH insulin typically peaks in its action around 6-10 hours after administration. Therefore, after administering NPH insulin at 7am, the client would be at most risk for a hypoglycemic reaction around 10pm. This is when the insulin is exerting its strongest effect, potentially leading to lower blood sugar levels. Monitoring for hypoglycemia during this time frame is crucial to ensure prompt intervention if needed.
Question 4 of 5
Toni's disease process involves a sacral plexus. Assessment should include:
Correct Answer: D
Rationale: When a patient's disease process involves the sacral plexus, such as in the case of Toni, it is important to assess aspects related to bladder problems, sexual activity, and bowel management. The sacral plexus plays a significant role in controlling functions such as bladder and bowel movements, as well as sexual function. Therefore, a comprehensive assessment including all of these areas is essential to provide holistic care for the patient and address any potential issues related to the sacral plexus involvement.
Question 5 of 5
The nurse should expect Mr. Gabatan to have some spasticity of the lower extremities. To prevent the development of contractures, careful consideration must be given to:
Correct Answer: D
Rationale: Proper positioning is crucial in preventing the development of contractures in patients with spasticity of the lower extremities. Contractures can result from prolonged positioning in a way that shortens the muscle-tendon unit. By ensuring proper positioning, the nurse can help maintain the muscles and joints in a neutral and extended position, minimizing the risk of contractures. This may involve positioning supports such as pillows, splints, or footboards to keep the limbs in an optimal position.