HESI RN
HESI Nutrition Exam
1. A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication:
- A. Can predispose to dysrhythmias
- B. May lead to oliguria
- C. May cause irritability and anxiety
- D. Sometimes alters consciousness
Correct answer: A
Rationale: The correct answer is A: Hypokalemia increases the risk of dysrhythmias when taking digoxin, making potassium intake crucial. Digoxin toxicity is more likely in patients with low potassium levels, leading to an increased risk of dysrhythmias. Choices B, C, and D are incorrect because hypokalemia in combination with digoxin is primarily associated with dysrhythmias rather than oliguria, irritability, anxiety, or alteration of consciousness.
2. The healthcare provider should recognize which of the following as an indication of dehydration in an elderly client?
- A. Skin turgor
- B. Dry mucous membranes
- C. Elevated temperature
- D. Increased pulse pressure
Correct answer: B
Rationale: Dry mucous membranes are a classic sign of dehydration, especially in elderly individuals. Dehydration can lead to decreased moisture in the mucous membranes, making them dry. Skin turgor, although commonly assessed for dehydration in younger individuals, may be less reliable in the elderly due to changes in skin elasticity. Elevated temperature is more indicative of an infection or other conditions. Increased pulse pressure is not typically associated with dehydration in the elderly.
3. Discharge instructions for a client taking alprazolam (Xanax) should include which of the following?
- A. Sedative hypnotics are effective analgesics
- B. Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares
- C. Caffeine beverages can increase the effect of sedative hypnotics
- D. Avoidance of excessive exercise and high temperature is recommended
Correct answer: B
Rationale: The correct answer is B. Alprazolam should not be stopped abruptly as it can cause rebound insomnia and nightmares; gradual tapering is necessary. Choice A is incorrect as sedative hypnotics are not primarily used as analgesics. Choice C is incorrect as caffeine can decrease the effects of sedative hypnotics rather than increase them. Choice D is incorrect as there is no specific recommendation to avoid excessive exercise or high temperature related to alprazolam use.
4. A client with a history of asthma is admitted to the emergency department with difficulty breathing. Which of these assessments is the highest priority for the nurse to perform?
- A. Auscultation of breath sounds
- B. Measurement of peak expiratory flow
- C. Observation of the client's use of accessory muscles
- D. Assessment of the client's skin color
Correct answer: A
Rationale: Auscultation of breath sounds is the highest priority assessment in a client with a history of asthma experiencing difficulty breathing. It helps the nurse evaluate the severity of the asthma exacerbation by listening for wheezing, crackles, or decreased breath sounds. This assessment guides treatment decisions, such as administering bronchodilators or oxygen therapy. Measurement of peak expiratory flow, although important in assessing asthma severity, may not be feasible in an emergency situation where immediate intervention is needed. Observation of accessory muscle use and assessment of skin color are also important assessments in asthma exacerbation, but auscultation of breath sounds takes precedence in determining the need for urgent interventions.
5. The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse's first action should be to
- A. Wrap the leg with elastic bandages
- B. Apply pressure at the bleeding site
- C. Reinforce the dressing and elevate the leg
- D. Remove the dressings and re-dress the incision
Correct answer: B
Rationale: In this scenario where the upper leg dressing becomes saturated with blood post-femoral popliteal bypass, the nurse's first action should be to apply pressure at the bleeding site. Applying pressure is essential to control hemorrhage and prevent further blood loss. Choice A is incorrect as wrapping the leg with elastic bandages would not address the immediate issue of controlling the bleeding. Choice C is incorrect because reinforcing the dressing and elevating the leg should come after controlling the bleeding. Choice D is incorrect as removing the dressings and re-dressing the incision should only be done after the bleeding is under control to prevent excessive blood loss.
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