HESI RN
HESI Nutrition Exam
1. The nurse is instructing a 65-year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to
- A. Exercise by doing weight-bearing activities
- B. Exercise to reduce weight
- C. Avoid exercise activities that increase the risk of fracture
- D. Exercise to strengthen muscles and thereby protect bones
Correct answer: A
Rationale: The correct answer is A: Exercise by doing weight-bearing activities. Weight-bearing activities help strengthen bones and prevent further bone loss in clients with osteoporosis. This type of exercise includes activities like walking, dancing, and weightlifting, which help improve bone density. Choice B is incorrect because the primary focus should be on bone health, not weight reduction. Choice C is incorrect as avoiding all exercise activities that increase the risk of fracture can lead to muscle weakness and a decline in bone health. Choice D is also incorrect because while strengthening muscles is beneficial, the emphasis for osteoporosis management should be on weight-bearing exercises specifically.
2. The nurse is monitoring a client who has just had a thyroidectomy. The client complains of tingling in the fingers and around the mouth. Which of these findings should the nurse assess first?
- A. Calcium level
- B. Chvostek's sign
- C. Trousseau's sign
- D. Serum potassium level
Correct answer: B
Rationale: The correct answer is B, Chvostek's sign. This is a classic sign of hypocalcemia, which can occur after a thyroidectomy due to injury or removal of the parathyroid glands. Hypocalcemia can lead to serious complications like tetany and laryngospasm, necessitating immediate attention. Assessing Chvostek's sign helps in early identification and management of hypocalcemia. Choices A, C, and D are not the priority in this situation. While assessing the calcium level is important for diagnosing hypocalcemia, the immediate concern is to identify clinical signs like Chvostek's sign, which indicate acute hypocalcemia. Trousseau's sign is also related to hypocalcemia but is not the most critical sign to assess first. Serum potassium level, although important for overall electrolyte balance, is not directly related to the client's current symptoms of tingling in the fingers and around the mouth.
3. 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.
4. 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.
5. During a physical assessment on a client who just had an endotracheal tube inserted, which finding would call for immediate action by the nurse?
- A. Breath sounds are auscultated bilaterally
- B. Mist is visible in the T-Piece
- C. Pulse oximetry of 88%
- D. Client is unable to speak
Correct answer: C
Rationale: A pulse oximetry reading of 88% indicates hypoxemia, which requires immediate intervention to ensure adequate oxygenation. In this scenario, the priority is to address the low oxygen saturation to prevent further complications. Auscultation of bilateral breath sounds is a positive finding as it indicates air entry into both lungs. Mist in the T-piece is expected in clients with an endotracheal tube, and the inability to speak is common due to the tube's placement.
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