HESI RN
HESI Nutrition Exam
1. A client is receiving intravenous antibiotics for the treatment of a severe infection. Which of these assessments is a priority for the nurse to perform?
- A. Monitor the client's temperature
- B. Assess the client's pain level
- C. Check the intravenous (IV) site for signs of phlebitis
- D. Monitor the client's respiratory status
Correct answer: C
Rationale: When a client is receiving intravenous antibiotics, checking the IV site for signs of phlebitis is a priority assessment for the nurse. Phlebitis is an inflammation of the vein, which can lead to serious complications such as infection and thrombosis. Monitoring the IV site helps prevent these complications and ensures the safe delivery of antibiotics. While monitoring the client's temperature, pain level, and respiratory status are important assessments, they are not the priority in this scenario where IV antibiotic administration requires close monitoring for complications like phlebitis.
2. The nurse is caring for a client with a history of peptic ulcer disease. Which of these findings would be most concerning to the nurse?
- A. A heart rate of 72 beats per minute
- B. A hemoglobin level of 12 g/dL
- C. The client reports black, tarry stools
- D. The client reports nausea and vomiting
Correct answer: C
Rationale: Black, tarry stools can indicate gastrointestinal bleeding, which is a serious complication of peptic ulcer disease. This finding suggests active bleeding in the gastrointestinal tract, requiring immediate attention. A normal heart rate of 72 beats per minute (choice A) is within the expected range. A hemoglobin level of 12 g/dL (choice B) is also within normal limits. Nausea and vomiting (choice D) are common symptoms associated with peptic ulcer disease but may not necessarily indicate active bleeding like black, tarry stools.
3. A nurse is assisting an adolescent client in the selection of complementary protein sources on the lunch menu. The client is a vegetarian who eats milk products but does not like beans. Which of the following food items should the nurse recommend?
- A. Peanut butter and jelly with enriched bread
- B. Baked potato with sour cream
- C. Bagel with cream cheese
- D. Fruit salad and carrot sticks
Correct answer: A
Rationale: Peanut butter and enriched bread provide complementary proteins, which are important for a vegetarian diet. Peanut butter is a good source of protein and when paired with enriched bread, it forms a complete protein source. Choice B, baked potato with sour cream, lacks complete protein. Choice C, bagel with cream cheese, also does not provide a complete protein source. Choice D, fruit salad and carrot sticks, do not contain sufficient protein to serve as a main protein source for a vegetarian diet.
4. The nurse is teaching an 87-year-old client methods for maintaining regular bowel movements. The nurse would caution the client to AVOID
- A. Glycerin suppositories
- B. Fiber supplements
- C. Laxatives
- D. Stool softeners
Correct answer: C
Rationale: The correct answer is C: Laxatives. Laxatives can be harsh on elderly clients, leading to dependence and potential side effects. While fiber supplements (B) and stool softeners (D) are generally safe options to promote regular bowel movements, laxatives should be used cautiously in older adults due to their potential risks. Glycerin suppositories (A) can also be a safe and effective option for managing constipation in the elderly, but laxatives should be avoided unless deemed necessary by a healthcare provider.
5. A nurse is reviewing a client's admission laboratory findings that indicate the client has hyponatremia. Which of the following laboratory findings should the nurse expect to be below the expected reference range?
- A. Magnesium
- B. Calcium
- C. Chloride
- D. Potassium
Correct answer: C
Rationale: The correct answer is C: Chloride. Chloride levels are typically low in cases of hyponatremia, as it often accompanies sodium loss. Magnesium (choice A) is not directly related to hyponatremia. Calcium (choice B) and Potassium (choice D) levels are usually not significantly affected by hyponatremia, making them less likely to be below the expected reference range in this scenario.
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