HESI RN
HESI Nutrition Exam
1. When reassigned to the emergency department, a nurse should understand that gastric lavage is a priority in which situation?
- A. An infant who has been identified to have botulism
- B. A toddler who ate a number of ibuprofen tablets
- C. A preschooler who swallowed powdered plant food
- D. A school-aged child who took a handful of vitamins
Correct answer: A
Rationale: The correct answer is A because gastric lavage is a priority for infants with botulism to remove toxins from the stomach. Botulism is a serious condition caused by a toxin produced by Clostridium botulinum bacteria. Gastric lavage helps in removing the toxin from the stomach. Choice B is incorrect because gastric lavage is not typically indicated for ibuprofen ingestion. Choice C is incorrect because gastric lavage is not the first-line treatment for ingesting powdered plant food. Choice D is incorrect because gastric lavage is not routinely performed for vitamin ingestion.
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 reinforcing teaching with a client who has a colostomy about appropriate food choices. Which of the following foods should the nurse include in the teaching?
- A. Eggs
- B. Grapes
- C. Pasta
- D. Dried fruits
Correct answer: A
Rationale: The correct answer is A: Eggs. Eggs are a good protein source and are less likely to cause blockage or odor issues in clients with colostomies. Grapes, pasta, and dried fruits can be problematic for individuals with colostomies as they may cause digestive issues, blockages, or increased gas production. Grapes have skins that are hard to digest, pasta can cause constipation or blockage, and dried fruits are high in fiber which can lead to blockages.
4. 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.
5. 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.
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