HESI RN
HESI RN Med Surg Exam 3 Questions
Extract:
Question 1 of 5
A client with type 1 diabetes mellitus (DM) is admitted to the hospital for an emergency cholecystectomy. The client explains to the nurse about experiencing difficulty at home in keeping blood glucose levels under 200 mg/dl (11.1 mmol/L). To prevent the client from developing diabetic ketoacidosis (DKA), which intervention is most important for the nurse to include in the plan of care?
Correct Answer: Testing urine for the presence of ketones is the most important intervention. Early detection of ketones allows for prompt intervention to prevent DKA.
Rationale:
Question 2 of 5
The home health nurse visits a client who has a serum sodium level of 123 me/L (123 mmol/L). To explore possible etiologist for this value, what question should the nurse ask the client?
Correct Answer: This question is most relevant because excessive water or ice chip intake can lead to dilutional hyponatremia. Identifying excessive fluid intake is critical in determining if this is the cause of the client's hyponatremia.
Rationale:
Question 3 of 5
A client with a history of diabetes mellitus and hypertension received new medication prescriptions three days ago. Today the client returns to the clinic reporting a severe headache and blurred vision. Which intervention should the nurse implement first?
Correct Answer: Obtaining a blood pressure reading is critical to rule out hypertensive crisis, a potential cause of severe headache and blurred vision.
Rationale:
Question 4 of 5
A client who weighs 176 pounds is admitted to the intensive care unit with a serum glucose level of 600 mg/dL (33.3 mmol/L). Regular insulin at a rate of 0.1 unit/kg/hour is prescribed. The pharmacy provides a solution of regular insulin 100 units/100 mL of normal saline. The nurse should set the infusion pump to deliver how many mL/hours?
Correct Answer: The nurse should set the pump to 8 mL/hour, calculated as 176 pounds ÷ 2.2 = 80 kg, 80 kg × 0.1 unit/kg/hour = 8 units/hour, 8 units ÷ (100 units/100 mL) = 8 mL/hour.
Rationale:
Question 5 of 5
An older client who is agitated, dyspneic, orthopneic, and using accessory muscles to breathe is admitted for further treatment. Initial assessment includes a heart rate of 128 beats/minute and irregular, respirations of 38 breaths/minute, blood pressure of 168/100 mm Hg, and oxygen saturation of 90% on room air. Wheezes and crackles are noted throughout bilateral lung fields. An hour after the administration of furosemide 60 mg IV push (IVP), which assessments should the nurse obtain to determine the client's response to treatment? Select all that apply.
Correct Answer: Lung sounds, oxygen saturation, and urinary output are direct measures of furosemide's effectiveness in reducing fluid overload and improving respiratory status.
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