the nurse is providing discharge teaching to a client with newly diagnosed type 2 diabetes mellitus which instruction is most important to prevent com
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Nursing Elites

HESI LPN

Adult Health 2 Exam 1

1. The nurse is providing discharge teaching to a client with newly diagnosed type 2 diabetes mellitus. Which instruction is most important to prevent complications?

Correct answer: A

Rationale: Regular monitoring of blood glucose levels is crucial in managing diabetes and preventing complications. This allows the client and healthcare team to make timely adjustments to the treatment plan. While maintaining a low-fat diet, exercising regularly, and taking medication as prescribed are all important aspects of diabetes management, monitoring blood glucose levels takes precedence as it provides real-time information about the client's condition and helps prevent acute complications.

2. The nurse observes a client with new-onset tachycardia. What should the nurse do first?

Correct answer: C

Rationale: When a client presents with new-onset tachycardia, the first action the nurse should take is to assess for any associated symptoms like chest pain or discomfort. This is important to differentiate the potential causes of tachycardia and guide appropriate interventions. Checking the client's temperature (Choice A) may be relevant in certain situations but is not the priority when tachycardia is observed. Administering prescribed beta-blockers (Choice B) should only be done after a comprehensive assessment and healthcare provider's orders. Monitoring the client's blood pressure (Choice D) is important, but assessing for chest pain or discomfort takes precedence in this scenario to rule out cardiac causes of tachycardia.

3. A client with a history of seizures is being discharged home. Which instruction is most important for the nurse to provide?

Correct answer: A

Rationale: The most important instruction for a client with a history of seizures being discharged home is to take their medication as prescribed. Consistent and timely intake of anti-seizure medication is vital in managing seizures and preventing episodes. While instructions like avoiding driving until the condition is stable, keeping a seizure diary, and avoiding alcohol consumption are important, none are as critical as ensuring proper medication adherence to control seizures effectively. Failure to take prescribed medications can lead to breakthrough seizures, compromising the patient's safety and seizure control.

4. During a severe asthma exacerbation in a client, what is the nurse's priority?

Correct answer: A

Rationale: During a severe asthma exacerbation, the nurse's priority is to administer a rescue inhaler immediately. This action helps open the airways and improve breathing, which is crucial in managing the exacerbation. Choice B, preparing for intubation, would be considered if the client's condition deteriorates and they are unable to maintain adequate oxygenation even after using the rescue inhaler. Encouraging deep breathing exercises (Choice C) may not be appropriate during a severe exacerbation as the client may struggle to breathe. While monitoring oxygen saturation levels (Choice D) is important, the immediate administration of a rescue inhaler takes precedence to address the acute breathing difficulty.

5. A client is admitted with a diagnosis of congestive heart failure (CHF). Which intervention is most important to include in the plan of care?

Correct answer: A

Rationale: The correct answer is A: Restrict fluid intake. Fluid restriction is crucial in the management of congestive heart failure (CHF) as it helps prevent fluid overload, which can exacerbate CHF symptoms. Choices B, C, and D are incorrect. Providing a high-sodium diet would worsen fluid retention and increase the workload of the heart. Encouraging vigorous exercise can strain the heart further in CHF patients. Administering bronchodilators is not the priority intervention for CHF.

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