a client with diabetes mellitus is scheduled for surgery and their blood glucose level is 280 mgdl what is the nurses priority action
Logo

Nursing Elites

HESI RN

HESI RN Exit Exam 2024 Quizlet Capstone

1. A client with diabetes mellitus is scheduled for surgery, and their blood glucose level is 280 mg/dL. What is the nurse's priority action?

Correct answer: A

Rationale: The correct answer is A: Administer insulin as prescribed. In clients with diabetes, high blood glucose levels can increase the risk of infection and impair healing after surgery. Administering insulin as prescribed helps reduce blood glucose to a safer level before surgery, preventing complications. Choice B is incorrect because delaying surgery without addressing the high blood glucose level does not address the immediate issue. Choice C is incorrect as checking the client's hemoglobin A1C level is not the priority when dealing with acute high blood glucose levels before surgery. Choice D is incorrect as administering IV fluids may help with hydration but does not directly address the high blood glucose level that needs immediate attention.

2. A client with tuberculosis is prescribed rifampin. What side effect should the nurse inform the client about?

Correct answer: B

Rationale: The correct answer is B. Rifampin can cause red-orange discoloration of bodily fluids, including urine, saliva, and tears. This is a harmless side effect, but clients should be informed beforehand to prevent alarm. Choice A is incorrect as orange-colored urine is not a sign of kidney dysfunction related to rifampin. Choice C is incorrect because rifampin is more commonly associated with liver toxicity rather than kidney dysfunction. Choice D is incorrect as vision changes are not a typical side effect of rifampin.

3. A client with peripheral artery disease reports leg cramps while walking. What intervention should the nurse recommend?

Correct answer: C

Rationale: For clients with peripheral artery disease, advising the client to take a short break when leg cramps occur and then continue walking is the appropriate intervention. This approach, known as interval walking, helps manage pain from intermittent claudication and improves circulation over time. Choice A is incorrect because immediate rest may not be necessary, and encouraging the client to resume walking after a short break is more beneficial. Choice B is incorrect since increasing potassium-rich foods may not directly address the underlying issue of peripheral artery disease causing cramps. Choice D is incorrect as avoiding walking altogether can lead to further deconditioning and worsen symptoms over time.

4. The nurse is caring for a client who is post-op after a hip replacement. Which of the following nursing actions is most appropriate to prevent dislocation of the hip?

Correct answer: B

Rationale: Using an abduction pillow between the client's legs is the most appropriate nursing action to prevent dislocation after hip replacement surgery. An abduction pillow helps maintain proper alignment and prevents the hip from dislocating. Placing the client in a high Fowler's position (Choice A) or encouraging them to sit upright for long periods (Choice D) may not provide the necessary support and stability needed to prevent hip dislocation. Encouraging the client to cross their legs while sitting (Choice C) can increase the risk of hip dislocation and should be avoided.

5. A client is admitted to the emergency department after a motor vehicle accident. The client has a Glasgow Coma Scale (GCS) score of 10. What does this score indicate?

Correct answer: B

Rationale: A Glasgow Coma Scale score of 10 falls into the range of moderate impairment, indicating the need for further assessment and monitoring. A GCS score of 10 suggests that the client is moderately impaired neurologically. Choices A, C, and D are incorrect because a GCS score of 10 does not indicate mild impairment, severe impairment, or normal neurological status, respectively.

Similar Questions

A client with osteoarthritis is prescribed acetaminophen. What is the most important teaching the nurse should provide?
A male client with heart failure presents with shortness of breath, audible wheezing, and pink frothy sputum. What action should the nurse take?
A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is?
A client with hyperparathyroidism is preparing for surgery. Which preoperative lab finding is most important to report?
A client with deep vein thrombosis (DVT) is prescribed anticoagulants. What should the nurse monitor closely?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses