HESI RN
HESI Nutrition Proctored Exam Quizlet
1. When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote
- A. Relaxation and sleep
- B. Deep breathing and coughing
- C. Incisional healing
- D. Range of motion exercises
Correct answer: B
Rationale: Effective pain management encourages deep breathing and coughing, which are crucial for preventing complications after thoracic surgery. These actions help prevent respiratory complications such as pneumonia and atelectasis, promote lung expansion, and improve oxygenation. While relaxation and sleep are important for recovery, the priority after a thoracotomy and lobectomy is to prevent respiratory issues. Incisional healing is important but not the primary focus immediately post-surgery. Range of motion exercises are not directly related to promoting recovery after thoracic surgery.
2. When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula
- A. Every four to six hours
- B. Continuously
- C. In a bolus
- D. Every hour
Correct answer: B
Rationale: When administering enteral feeding through a jejunostomy tube, the nurse should administer the formula continuously. Continuous feeding is essential for optimal nutrient absorption and to prevent complications. Administering the formula every four to six hours, in a bolus, or every hour may lead to inadequate nutrition, improper absorption, and an increased risk of complications such as aspiration or dumping syndrome, making these choices incorrect.
3. In a client with chronic kidney disease having a serum potassium level of 6.5 mEq/L, which assessment is the most critical for the nurse to perform?
- A. Neurological status
- B. Cardiac status
- C. Respiratory status
- D. Gastrointestinal status
Correct answer: B
Rationale: Corrected Rationale: Assessing cardiac status is crucial in hyperkalemia as high potassium levels can result in life-threatening arrhythmias. Monitoring the heart rhythm and ECG findings is essential to prevent cardiac complications. Neurological status, respiratory status, and gastrointestinal status are important assessments too, but in the context of hyperkalemia, cardiac status takes precedence due to the immediate risk of cardiac arrhythmias.
4. The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown?
- A. Place the client in the wheelchair for four hours each day
- B. Pad the bony prominences
- C. Reposition every two hours
- D. Massage reddened bony prominence
Correct answer: C
Rationale: Repositioning every two hours is the most effective measure in preventing skin breakdown for a client with a CVA. This practice helps to relieve pressure on the skin, reducing the risk of pressure ulcers. Placing the client in a wheelchair for extended periods (Choice A) can increase pressure on specific areas, leading to skin breakdown. Padding bony prominences (Choice B) can provide some protection but may not address the root cause of pressure ulcers. Massaging reddened bony prominences (Choice D) can potentially worsen the condition by causing further damage to already compromised skin.
5. The nurse assesses a 72-year-old client who was admitted for right-sided congestive heart failure. Which of the following would the nurse anticipate finding?
- A. Decreased urinary output
- B. Jugular vein distention
- C. Pleural effusion
- D. Bibasilar crackles
Correct answer: B
Rationale: In right-sided congestive heart failure, the nurse would anticipate finding jugular vein distention. This occurs due to increased venous pressure, leading to the distention of the jugular veins in the neck. Choices A, C, and D are incorrect. Decreased urinary output is not typically associated with right-sided heart failure; pleural effusion and bibasilar crackles are more commonly seen in conditions like left-sided heart failure.
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