HESI RN
HESI RN Fundamentals II Questions
Extract:
History and physical
The client is a 52-year-old female with a history of obesity, type 2 diabetes mellitus, and hypertension. She is in the hospital for treatment of cellulitis of the right leg. The client has a peripherally inserted central catheter (PICC) in her right antecubital vein. She is currently on day 4 of her antibiotic course.
Nurses notes :
The client had a large, loose stool.
Laboratory Results
Laboratory Test Result Reference Range
Blood Glucose 104 mg/dL (5.8 mmol/L) 74 to 106 mg/dL. (4.1 to 5.9 mmol/L)
Orders:
• Vital signs every 4 hours
• Regular diet
• Cefazolin 1 g IV every 8 hours for 5 days
• Metformin 1,000 mg PO every 12 hours
• Point of care blood glucose check every 4 hours
Patient Data
Question 1 of 5
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
Correct Answer:
Rationale: Condition:
Osmotic diarrhea
osmotic diarrhea. This type of diarrhea is often caused by an imbalance in the osmolality of the intestinal contents, which can be due to certain medications or dietary factors. In this case, the client's recent antibiotic therapy and diet might contribute to this condition.
Actions to Take:
Collect stool for culture – This can help determine if there is an infectious or bacterial component contributing to the diarrhea.
Start a high fiber diet – Increasing dietary fiber can help in managing diarrhea by increasing stool bulk and improving consistency.
Parameters to Monitor:
Serum potassium – Osmotic diarrhea can lead to electrolyte imbalances, and monitoring potassium levels helps to detect potential deficiencies.
Serum ketones – This can help to evaluate if the client is in a state of ketosis due to potential malabsorption or significant diarrhea.
Extract:
Question 2 of 5
The nurse assesses an older adult client's ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client's posture is upright, and the gait is smooth and steady. Which action should the nurse take next?
Correct Answer: A
Rationale: Activity tolerance assesses functional capacity.
Question 3 of 5
The nurse enters a client's room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?
Correct Answer: B
Rationale: Acknowledging distress and offering flexibility respects client needs.
Question 4 of 5
The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?
Correct Answer: B
Rationale: Edema interferes with oximeter accuracy.
Question 5 of 5
The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL vial. Which action should the nurse perform with the remainder of the medication?
Correct Answer: A
Rationale: Witnessed disposal ensures accountability.