a client with diabetes mellitus reports tingling in their feet what is the nurses best intervention
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Nursing Elites

HESI RN

HESI RN Exit Exam 2023 Capstone

1. A client with diabetes mellitus reports tingling in their feet. What is the nurse's best intervention?

Correct answer: C

Rationale: The correct intervention for a client with diabetes mellitus experiencing tingling in their feet is to teach the client about blood sugar control and foot care. This is essential because tingling in the feet can be a sign of neuropathy, a common complication of diabetes. Educating the client on maintaining proper blood sugar levels and foot care practices can help manage neuropathy symptoms and prevent complications like ulcers or infections. Advising the client to avoid tight shoes (Choice A) may help with comfort but does not address the underlying issue. Referring the client to a podiatrist (Choice B) is important for foot care but does not directly address blood sugar control. Administering insulin (Choice D) is not the priority for managing tingling in the feet related to neuropathy.

2. A client with a history of asthma reports using an albuterol inhaler more frequently than prescribed. Which action should the nurse take first?

Correct answer: C

Rationale: Increased use of a rescue inhaler like albuterol may indicate worsening asthma symptoms. The nurse should first assess the client's respiratory status to determine the severity of the issue and the next steps in care. Option A is not the first action because assessing the client's condition should precede notifying the healthcare provider. Option B, scheduling a pulmonary function test, is not the priority as immediate assessment of the client's respiratory status is crucial. Instructing the client to decrease inhaler use should come after assessing the client's condition to ensure the appropriate intervention.

3. The nurse is preparing a female client for discharge after being treated for a urinary tract infection (UTI). Which statement by the client indicates a need for further teaching?

Correct answer: A

Rationale: The correct answer is A. Using douches is not recommended as it can disrupt the natural flora and increase the risk of infections. Choices B, C, and D are all correct statements that can help prevent UTIs. Drinking an adequate amount of water helps flush out bacteria, avoiding tight-fitting clothing promotes ventilation and reduces moisture, and wiping from front to back prevents the spread of bacteria from the anal region to the urethra.

4. A client with hyperthyroidism is admitted for total thyroidectomy. What is the nurse's priority post-operative intervention?

Correct answer: A

Rationale: The correct answer is to monitor the client's calcium levels for hypocalcemia. After a total thyroidectomy, there is a risk of accidental removal or damage to the parathyroid glands, leading to hypocalcemia. This complication can manifest within the first 24-48 hours post-op. Monitoring calcium levels is crucial to prevent serious complications such as tetany or seizures. While monitoring for respiratory distress is important, it is not the priority in this case. Administering oral calcium supplements should only be done based on the healthcare provider's prescription and after assessing the client's calcium levels. Elevating the head of the bed to 45 degrees is beneficial for respiratory function but is not the priority intervention for a client at risk for hypocalcemia post-thyroidectomy.

5. A client with diabetes mellitus reports feeling shaky, dizzy, and sweaty. The nurse checks the client's blood glucose level and it is 55 mg/dL. What is the nurse's next action?

Correct answer: C

Rationale: A blood glucose level of 55 mg/dL indicates hypoglycemia, which should be treated with a fast-acting carbohydrate to quickly raise the blood sugar. Administering 15 grams of a fast-acting carbohydrate, such as glucose tablets or juice, is the appropriate initial intervention for hypoglycemia. Giving a glucagon injection is reserved for severe cases or when the client is unconscious. Encouraging the client to eat a high-protein snack is not appropriate for treating acute hypoglycemia, as it is a slower-acting form of glucose. Rechecking the blood glucose level is important but should occur after providing immediate treatment to raise the blood sugar level.

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