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HESI RN MED-SURG 3
Total Questions : 51
Showing 10 questions, Sign in for moreA client is being prepared for discharge. The client's discharge plan includes resuming the lower dose of lithium and continuing to take desmopressin in oral form. The nurse teaches the client about safety measures.
Click to indicate which client statements indicate teaching was effective related to management of diabetes insipidus and care. Each row must have only one option selected.
Explanation
- I will monitor my urine output and pay attention to the volume and color. Clients with DI must monitor urine output closely because polyuria and diluted urine indicate under-treatment, while sudden reduced output and darker urine may suggest fluid retention or excessive desmopressin dosing.
- I will always wear my medical alert bracelet. A medical alert bracelet is essential for emergency situations since DI can lead to severe dehydration and electrolyte imbalances if left untreated. It ensures that emergency responders are aware of the condition if the client is unable to communicate.
- I will use the same scale and wear a similar amount of clothing when I take my weekly weight. Monitoring body weight trends is crucial in DI management, as sudden weight gain may indicate fluid retention (over-treatment), while weight loss may suggest dehydration. Using a consistent method ensures accurate tracking.
- If I gain more than 2.2 lb (1 kg), I will go to the emergency department (ED). A sudden weight gain may suggest fluid retention from over-treatment, but mild fluctuations are not always an emergency. Instead, the client should report significant weight changes to their healthcare provider to assess medication adjustments.
- If I become thirstier, I may need another dose of the medication. While increased thirst may indicate under-treatment, self-adjusting the desmopressin dose is not recommended without consulting a healthcare provider. The client should track symptoms and report persistent thirst to determine if a dosage change is necessary.
A client diagnosed with pancreatitis reports severe epigastric pain. After administering a narcotic analgesic, the client insists on Tip sitting up and leaning forward. Which action should the nurse implement?
After an endotracheal tube (ETT) is initially placed for a client requiring mechanical ventilation, which intervention should the nurse implement first?
The nurse assesses the telemetry monitor of a client who is 24 hours postoperative from having a permanent pacemaker insertion. The nurse observes that a pacemaker spike is present before each QRS complex in lead II of the electrocardiogram (ECG). Which intervention should the nurse implement?
After intubating a client, correct placement of the endotracheal tube (ETT) is confirmed with a chest x-ray. Which intervention should the nurse implement to ensure that the ETT placement is maintained?
The client is a 59-year-old female with hyperosmolar hyperglycemic syndrome (HHS). She developed abdominal pain several days ago and nausea starting yesterday. This morning, she was extremely drowsy and confused at work. Her coworker brought her to the hospital.
1200
Admit to the medical intensive care unit
Vital signs every hour
0.9% sodium chloride IV infusion at 200mL/hr
Insulin IV infusion at 0.1 unit/kg/hr
Strict intake and output
Point of care blood glucose every hour
Electrolytes and arterial blood gas (ABG) every 4 hours
1600:
Blood Glucose 250 mg/dL (74-106 mg/dL)
Sodium (Na⁺) 152 mEq/L (135-145 mEq/L)
Potassium (K⁺) 3.2 mEq/L (3.5-5.0 mEq/L)
Bicarbonate (HCO₃⁻) 20 mEq/L (22-26 mEq/L)
pH (ABG) 7.35 (7.35-7.45)
Based on the client's laboratory values at 1600, which are appropriate nursing actions? Select all that apply.
A client has a chest tube connected to a closed water-seal drainage system with suction. Which equipment should the nurse always have available at the client's bedside?
A client is admitted to the neurological intensive care unit after having just sustained a C5 spinal cord injury (SCI). Which assessment finding for this client warrants immediate intervention by the nurse?
The nurse is monitoring for signs of increased intracranial pressure (ICP) in a client who attempted suicide by jumping from a tenth floor balcony. The client is intubated and mechanically ventilated. Which intervention should the nurse implement to minimize rises in ICP?
The nurse assesses a client postoperatively who has an arterial line in the right radial artery. Assessment findings include pallor, paresthesia, and slow capillary refill in the client's right-hand fingers. Which action should the nurse take?
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