the nurse is teaching a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis what statement indicates to the nurs
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HESI LPN

HESI PN Exit Exam 2023

1. The nurse is teaching a client with diabetes mellitus how to differentiate between hypoglycemia and ketoacidosis. What statement indicates to the nurse that the client has an understanding of this condition?

Correct answer: D

Rationale: The correct answer is D. Shakiness is a symptom of hypoglycemia, which is low blood sugar. Taking glucose can help raise blood sugar levels quickly in this situation. Fruity breath odor and excessive urination are signs of ketoacidosis, a complication of diabetes involving high levels of ketones in the blood. Blurred vision can be a symptom of high blood sugar, but it is not specific to hypoglycemia.

2. An 8-year-old is placed in 90-90 traction for a fractured femur resulting from a motor vehicle collision. Which finding requires further action by the nurse?

Correct answer: C

Rationale: The correct answer is C. In 90-90 traction, the weights should hang freely and not touch the foot of the bed to maintain proper traction and bone alignment. Option A is not necessarily a concern as bowel movements can be influenced by various factors, including diet changes and pain medication. Option B indicates good caregiver involvement, promoting comfort and preventing complications. Option D demonstrates neurovascular function, which is a positive finding. Therefore, the weights touching the foot of the bed is the finding that requires immediate attention to ensure the effectiveness of the traction.

3. A client tells the PN that she has a family history of cancer and has increased the amount of dairy products in her diet to reduce her risk of getting cancer. How should the PN respond?

Correct answer: D

Rationale: Increasing fruits and vegetables in the diet is more beneficial in reducing cancer risk due to their high levels of antioxidants and fiber, which help protect against cancer. While exercise is important for overall health, in this context, focusing on fruits and vegetables is more relevant to reducing cancer risk than exercise alone. Providing information about cancer warning signs is not directly addressing the client's dietary choice. While Vitamin D is essential for various health aspects, the primary focus here should be on a diet rich in fruits and vegetables for cancer risk reduction.

4. The practical nurse is caring for a client who had a total laryngectomy, left radical neck dissection, and tracheostomy. The client is receiving nasogastric tube feedings via an enteral pump. Today the rate of feeding is increased from 50 ml/hr to 75 ml/hr. What parameter should the PN use to evaluate the client's tolerance to the rate of the feeding?

Correct answer: B

Rationale: Monitoring gastric residual volumes helps to assess how well the client is tolerating the increased feeding rate. High residuals may indicate delayed gastric emptying, which could lead to complications like aspiration. This helps in adjusting the feeding plan as necessary. Daily weight (Choice A) is not the most appropriate parameter to evaluate tolerance to feeding rate changes. Bowel sounds (Choice C) and urinary/stool output (Choice D) are important assessments but do not directly indicate tolerance to enteral feeding rate changes.

5. A client who is at full-term gestation is in active labor and complains of a cramp in her leg. Which intervention should the nurse implement?

Correct answer: D

Rationale: The correct intervention for a client in active labor complaining of a leg cramp is to extend the leg and flex the foot. This action helps stretch the muscles that are cramping, providing relief. Massaging the calf and foot (Choice A) may not be as effective for relieving the cramp. Elevating the leg above the heart (Choice B) is not indicated for a leg cramp. Checking the pedal pulse in the affected leg (Choice C) is unrelated to addressing the leg cramp.

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