HESI RN
HESI Nutrition Exam
1. 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.
2. During an excretory urogram, which observation made by the nurse indicates a complication?
- A. The client complains of a salty taste in the mouth when the dye is injected
- B. The client's entire body turns a bright red color
- C. The client states 'I have a feeling of getting warm.'
- D. The client gags and complains 'I am getting sick.'
Correct answer: B
Rationale: The observation of the client's entire body turning a bright red color during an excretory urogram indicates a severe reaction to the dye, which is a significant complication. This reaction is likely due to an allergic response and requires immediate medical attention. The other choices do not signify a severe complication: choice A could be a normal taste sensation related to the procedure, choice C may indicate a mild reaction, and choice D could be a common side effect of nausea without indicating a severe complication requiring immediate intervention.
3. A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during the first 12 hours after admission?
- A. Side-lying on the left with the head elevated 10 degrees
- B. Side-lying on the left with the head elevated 35 degrees
- C. Side-lying on the right with the head elevated 10 degrees
- D. Side-lying on the right with the head elevated 35 degrees
Correct answer: A
Rationale: The correct position for a client with viral pneumonia affecting 2/3 of the right lung is side-lying on the left with the head elevated 10 degrees. This position helps maximize lung expansion and oxygenation in cases of pneumonia affecting the right lung. Choice B is incorrect as excessive elevation can put pressure on the lung, and choices C and D are incorrect as side-lying on the right would not be beneficial for a client with pneumonia in the right lung.
4. The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is
- A. Heart rate
- B. Pedal pulses
- C. Lung sounds
- D. Pupil responses
Correct answer: D
Rationale: Assessing pupil responses is crucial in a client with hypertensive crisis to monitor for signs of increased intracranial pressure, which can indicate potential neurological complications. While heart rate, pedal pulses, and lung sounds are important assessments, they do not take precedence over neurological assessments in this critical situation.
5. While assessing several clients in a long-term health care facility, which client is at the highest risk for developing decubitus ulcers?
- A. A 79-year-old malnourished client on bed rest
- B. An obese client who uses a wheelchair
- C. A client who had 3 incontinent diarrhea stools
- D. An 80-year-old ambulatory diabetic client
Correct answer: A
Rationale: The correct answer is A: A 79-year-old malnourished client on bed rest. This client is at the highest risk for developing decubitus ulcers due to poor nutrition and immobility. Malnutrition can impair tissue healing and increase susceptibility to skin breakdown, while prolonged bed rest can lead to pressure ulcers. Choice B is incorrect because obesity can cushion pressure points and reduce the risk of pressure ulcers. Choice C is incorrect as incontinence predisposes to moisture-associated skin damage rather than pressure ulcers. Choice D is incorrect as an ambulatory client is less likely to develop pressure ulcers compared to bedridden clients.
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