HESI RN
HESI Nutrition Exam
1. A 60-year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void?
- A. Have him drink several glasses of water
- B. Crede the bladder from the bottom to the top
- C. Assist him to stand by the side of the bed to void
- D. Wait 2 hours and have him try to void again
Correct answer: C
Rationale: Assisting the client to stand by the side of the bed to void is the most appropriate action. This position can help stimulate voiding due to gravity and normal positioning. Having the client drink water (Choice A) may help, but assisting him to stand is more effective. Crede maneuver (Choice B) is not recommended as it can increase the risk of bladder trauma. Waiting for 2 hours (Choice D) without taking any action is not proactive in addressing the client's inability to void.
2. To prevent unnecessary hypoxia during suctioning of a tracheostomy, what must the nurse do?
- A. Apply suction for no more than 10 seconds
- B. Maintain a sterile technique
- C. Lubricate 3 to 4 inches of the catheter tip
- D. Withdraw the catheter in a circular motion
Correct answer: A
Rationale: To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must apply suction for no more than 10 seconds. Prolonged suctioning can lead to hypoxia by removing too much oxygen from the patient. Maintaining a sterile technique (choice B) is important to prevent infection but does not directly relate to preventing hypoxia. Lubricating the catheter tip (choice C) helps with the insertion process but does not specifically address hypoxia prevention. Withdrawing the catheter in a circular motion (choice D) is not a standard practice during tracheostomy suctioning and does not contribute to preventing hypoxia.
3. A nurse is providing anticipatory guidance to the parents of a newborn about feeding skills. Which of the following is not an infant's feeding skill?
- A. Pushes solid objects from mouth
- B. Eats foods that are higher in fat
- C. Begins experimenting with a spoon
- D. Eats pieces of soft, cooked food
Correct answer: B
Rationale: The correct answer is B. When discussing infant feeding skills, it is important to note that eating foods higher in fat is not considered a specific feeding skill for newborns. The typical progression of feeding skills includes pushing solid objects from the mouth, eating pieces of soft, cooked food, drinking from a cup held by another person, and experimenting with a spoon. Choices A, C, and D correspond to the expected developmental sequence of feeding skills for infants, making them incorrect answers in this context.
4. A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse?
- A. Cut the child's hair short to remove the nits
- B. Apply warm soaks to the head twice daily
- C. Wash the child's linen and clothing in a bleach solution
- D. Application of pediculicides
Correct answer: D
Rationale: Pediculicides are the recommended treatment for lice and should be used to eliminate the infestation.
5. A nurse is reinforcing teaching with a client who has Crohn's disease about foods to include in her diet. Which of the following foods should the nurse include in the teaching?
- A. Vanilla milkshake
- B. Buttered popcorn
- C. Broccoli
- D. Grilled chicken breast
Correct answer: D
Rationale: Grilled chicken breast is a high-protein, low-fiber food that is well-tolerated by clients with Crohn's disease. Crohn's disease is an inflammatory bowel disease that often requires a low-fiber diet to reduce irritation to the digestive tract. Vanilla milkshake is high in dairy and sugar content, which may trigger symptoms in some individuals with Crohn's disease. Buttered popcorn and broccoli are high in fiber, which can be difficult for individuals with Crohn's disease to digest and may exacerbate symptoms.
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