which of the following nursing interventions should be taken for a client who complains of nausea and vomits one hour after taking his glyburide diabe
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HESI Leadership and Management Quizlet

1. Which of the following nursing interventions should be taken for a client who complains of nausea and vomits one hour after taking his glyburide (DiaBeta)?

Correct answer: C

Rationale: After a client complains of nausea and vomits one hour after taking glyburide, the priority nursing intervention should be to monitor blood glucose closely and look for signs of hypoglycemia. Vomiting could indicate that the glyburide was not properly absorbed, potentially leading to hypoglycemia. Administering glyburide again (Choice A) could worsen hypoglycemia. Administering subcutaneous insulin (Choice B) is not appropriate without assessing the blood glucose first. Monitoring for signs of hyperglycemia (Choice D) is not the immediate concern in this situation.

2. Which technique or method is used to determine whether or not the patient has an irregular pulse?

Correct answer: A

Rationale: An apical pulse check is used to determine if the patient has an irregular pulse. The apical pulse is located at the point of maximal impulse (PMI) and is assessed using a stethoscope. Choice B, inspection, involves visual examination and is not used to assess pulse irregularities. Choice C, auscultation, involves listening to internal sounds using a stethoscope, which can be used to assess heart sounds but not specifically for pulse irregularities. Choice D, percussion, is a technique used to assess the density of body tissues or detect abnormal masses and is not used to determine pulse irregularities.

3. Select the nursing theorist who is accurately paired with the theory or model of nursing that they are credited with.

Correct answer: D

Rationale: The correct answer is D. Hildegard Peplau is credited with the Interpersonal Relations Model in nursing. Faye Glenn Abdullah is associated with the Developmental Theory of Nursing. Imogene King developed the Theory of Goal Attainment. Virginia Henderson is known for the Definition of Nursing. Therefore, among the given options, only Hildegard Peplau is correctly paired with the Interpersonal Relations Model.

4. How many calories per kilogram does an average full-term infant require when the infant is around 1-2 months old?

Correct answer: B

Rationale: An average full-term infant requires about 120 calories per kilogram per day at 1-2 months old. This amount is essential for their growth and development during this critical stage. Choices A, C, and D are incorrect as they provide calorie amounts that are either too high or too low for an average full-term infant at 1-2 months old, which could potentially lead to health issues or inadequate nutrition.

5. A client is in DKA, secondary to infection. As the condition progresses, which of the following symptoms might the nurse see?

Correct answer: A

Rationale: In diabetic ketoacidosis (DKA), as the condition progresses, the body tries to compensate for the acidic environment by increasing the respiratory rate, leading to Kussmaul's respirations. The accumulation of ketones in the body causes a fruity odor on the breath. Option A is correct because Kussmaul's respirations and a fruity odor on the breath are classic signs of DKA. Option B is incorrect because shallow respirations are not typically seen in DKA, and severe abdominal pain is more commonly associated with conditions like pancreatitis. Option C is incorrect as decreased respirations are not a typical finding in DKA, and increased urine output is more commonly seen in conditions like diabetes insipidus. Option D is incorrect because Cheyne-Stokes respirations are not characteristic of DKA, and foul-smelling urine is not a prominent symptom in this condition.

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