HESI RN
HESI Nutrition Proctored Exam Quizlet
1. The nurse is caring for a client receiving a blood transfusion who develops urticaria half an hour after the transfusion has begun. What is the first action the nurse should take?
- A. Stop the infusion
- B. Slow the rate of infusion
- C. Take vital signs and observe for further deterioration
- D. Administer Benadryl and continue the infusion
Correct answer: A
Rationale: In the scenario of a client developing urticaria during a blood transfusion, the immediate priority for the nurse is to stop the infusion. This action is crucial to prevent further administration of the allergen causing the reaction. Slowing the rate of infusion (Choice B) may not be sufficient to address the allergic response effectively. While monitoring vital signs (Choice C) is important, stopping the infusion takes precedence to prevent worsening of the reaction. Administering Benadryl (Choice D) should be considered after stopping the infusion, following the healthcare provider's orders, and assessing the client's condition.
2. A client who has received treatment for kidney stones should be reminded to increase intake of which of the following?
- A. Tea
- B. Sodium
- C. Water
- D. Protein
Correct answer: C
Rationale: The correct answer is C: Water. Increasing water intake helps prevent the formation of new kidney stones by diluting the urine. Tea (Choice A) contains oxalates, which can contribute to kidney stone formation. Sodium (Choice B) should be limited to prevent the risk of certain types of kidney stones. Protein (Choice D) intake should be moderate as excessive protein consumption may increase the risk of kidney stones. Therefore, advising the client to increase water intake is the most appropriate recommendation to prevent the recurrence of kidney stones.
3. A client is being maintained on heparin therapy for deep vein thrombosis. The nurse must closely monitor which of the following laboratory values?
- A. Bleeding time
- B. Platelet count
- C. Activated PTT
- D. Clotting time
Correct answer: C
Rationale: Activated PTT is the correct lab value to monitor for clients on heparin therapy. Activated PTT (partial thromboplastin time) helps assess the effectiveness of heparin therapy by measuring the time it takes for blood to clot. Monitoring activated PTT ensures that the client is within the therapeutic range of heparin to prevent both clotting and bleeding complications. Bleeding time (Choice A) and platelet count (Choice B) are not specific indicators of heparin therapy effectiveness. Clotting time (Choice D) is not as sensitive as activated PTT in monitoring heparin therapy.
4. 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.
5. The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250, and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern?
- A. Diminished bowel sounds
- B. Loss of appetite
- C. A cold, pale lower leg
- D. Tachypnea
Correct answer: C
Rationale: A cold, pale lower leg is the most concerning finding as it indicates poor blood flow, potentially suggesting a serious circulatory problem that requires immediate attention. Diminished bowel sounds, loss of appetite, and tachypnea may be relevant but are not as indicative of a critical circulatory issue as a cold, pale lower leg.
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