HESI RN
HESI RN Nursing Leadership and Management Exam 5
1. Which of the following is an example of nonmaleficence in nursing practice?
- A. Administering pain medication as prescribed to prevent patient discomfort.
- B. Ensuring that a patient does not receive a treatment that they have refused.
- C. Ensuring that a patient receives appropriate care without causing harm.
- D. Encouraging a patient to express their concerns and fears about a procedure.
Correct answer: B
Rationale: Nonmaleficence is the ethical principle of doing no harm. In nursing practice, ensuring that a patient does not receive a treatment they have refused is an example of nonmaleficence. Choice A focuses on beneficence by providing pain relief. Choice C is more aligned with beneficence as it emphasizes providing appropriate care without harm. Choice D pertains to patient communication but does not directly address the concept of nonmaleficence.
2. A client with DM is experiencing symptoms of hypoglycemia. Which action should the nurse take first?
- A. Give the client a glass of orange juice.
- B. Administer insulin as ordered.
- C. Check the client's blood glucose level.
- D. Notify the healthcare provider.
Correct answer: C
Rationale: The correct first action when a client with DM is experiencing symptoms of hypoglycemia is to check the client's blood glucose level. This step is crucial to confirm hypoglycemia before initiating any treatment. Giving the client orange juice (Choice A) is a common intervention for treating hypoglycemia, but it should not be done before confirming the blood glucose level. Administering insulin (Choice B) is not appropriate for hypoglycemia as it would further decrease the blood glucose levels. Notifying the healthcare provider (Choice D) can be important, but the immediate priority is to assess the blood glucose level to guide treatment.
3. The client has been vomiting and has had numerous episodes of diarrhea. Which laboratory test should the nurse monitor?
- A. Serum calcium.
- B. Serum phosphorus.
- C. Serum potassium.
- D. Serum sodium.
Correct answer: C
Rationale: During episodes of vomiting and diarrhea, there is a risk of significant potassium loss, leading to potential electrolyte imbalances. Monitoring serum potassium levels is crucial in this situation to assess and manage any abnormalities promptly. Serum calcium (Choice A) is not typically affected by vomiting and diarrhea. Serum phosphorus (Choice B) levels are not commonly altered by these symptoms. Serum sodium (Choice D) may be affected in severe cases of dehydration, but potassium monitoring is a higher priority due to its potential for rapid depletion in vomiting and diarrhea.
4. A client at risk for hypokalemia is being instructed by a nurse about foods high in potassium that should be included in the daily diet. The nurse determines that the client understands the food sources of potassium if the client states that the food item lowest in potassium is:
- A. Apples
- B. Carrots
- C. Spinach
- D. Avocado
Correct answer: A
Rationale: The correct answer is 'Apples.' Apples are the lowest in potassium among the given options. Carrots, spinach, and avocados are all higher in potassium content compared to apples. Carrots and spinach are vegetables known to have a moderate amount of potassium. Avocados, on the other hand, are a high-potassium fruit and would not be the lowest in potassium among the choices provided.
5. How often should rotation sites for insulin injection be separated from one another?
- A. Every third day.
- B. Every week.
- C. Every 2-3 weeks.
- D. Every 2-4 weeks.
Correct answer: C
Rationale: Insulin injection sites should be rotated every 2-3 weeks to prevent lipodystrophy and ensure proper insulin absorption. Option A ('Every third day') is too frequent and does not allow enough time for the previous site to heal properly. Option B ('Every week') might not provide adequate time for the tissue to recover. Option D ('Every 2-4 weeks') could potentially lead to overuse of a single injection site, increasing the risk of lipodystrophy and inconsistent insulin absorption. Therefore, the recommended interval of every 2-3 weeks is optimal for insulin injection site rotation.
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