HESI RN
Nutrition HESI Practice Exam
1. A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action?
- A. Clamp the chest tube
- B. Call the surgeon immediately
- C. Prepare for blood transfusion
- D. Continue to monitor the rate of drainage
Correct answer: D
Rationale: In this scenario, the most appropriate nursing action is to continue to monitor the rate of drainage. Clamping the chest tube is not recommended as it can lead to a tension pneumothorax. Calling the surgeon immediately may not be necessary at this point unless the drainage rate significantly increases or other concerning symptoms develop. Preparing for a blood transfusion is premature without further assessment and monitoring of the client's condition. Monitoring the rate of drainage allows the nurse to assess for any potential complications and ensure that the drainage amount is within expected limits.
2. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first?
- A. Institute seizure precautions
- B. Monitor neurologic status every hour
- C. Place in respiratory/secretion precautions
- D. Cefotaxime IV 50 mg/kg/day divided q6h
Correct answer: C
Rationale: The correct answer is to place the child in respiratory/secretion precautions first. Meningococcal meningitis is highly contagious, and respiratory precautions are essential to prevent the spread of the infection. Seizure precautions may be necessary but are not the priority upon admission. Monitoring neurologic status is important but not the initial action needed. While antibiotic therapy like Cefotaxime is crucial, implementing isolation precautions to prevent transmission takes precedence in this situation.
3. A client with a history of seizures is being monitored with an electroencephalogram (EEG). Which of these interventions should the nurse perform to prepare the client for the test?
- A. Instruct the client to avoid caffeine for 8 hours before the test
- B. Explain the procedure to the client and obtain consent
- C. Administer anticonvulsant medication as ordered
- D. Instruct the client to wash their hair the morning of the test
Correct answer: A
Rationale: Instructing the client to avoid caffeine for 8 hours before the EEG is essential. This intervention helps ensure accurate test results by preventing stimulation of the nervous system, which could interfere with the interpretation of the brain's electrical activity. Explaining the procedure and obtaining consent are important steps but do not directly impact the test results. Administering anticonvulsant medication as ordered is a medical intervention and not a preparation step for the test. Instructing the client to wash their hair the morning of the test is not necessary for EEG preparation.
4. A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture?
- A. Some needles go as deep as 3 inches, depending on where they're placed in the body and what the treatment is for. The needles are usually left in for 15 to 30 minutes.
- B. In traditional Chinese medicine, imbalances in the basic energetic flow of life — known as qi or chi — are thought to cause illness.
- C. The flow of life is believed to flow through major pathways in your body rather than nerve clusters.
- D. By inserting extremely fine needles into some of the over 400 acupuncture points in various combinations, it is believed that energy flow will rebalance to allow the body's natural healing mechanisms to take over.
Correct answer: C
Rationale: The belief stated in option C is incorrect about acupuncture. Acupuncture is based on the concept of qi flowing through major pathways in the body, known as meridians, rather than nerve clusters. This traditional Chinese medicine practice aims to balance the flow of qi to promote health and healing. Options A, B, and D are consistent with the principles of acupuncture and are not incorrect beliefs. Option A describes the depth and duration of needle placement, option B explains the role of imbalances in qi flow causing illness, and option D outlines how acupuncture helps rebalance energy flow for the body's natural healing mechanisms.
5. When another nurse enters the room in response to a call, after checking the client's pulse and respirations during CPR on an adult in cardiopulmonary arrest, what should be the function of the second nurse?
- A. Relieve the nurse performing CPR
- B. Go get the code cart
- C. Participate with the compressions or breathing
- D. Validate the client's advanced directive
Correct answer: C
Rationale: The correct answer is to participate in compressions or breathing. This is essential to ensure continuous and effective CPR. Relieving the nurse performing CPR (Choice A) is not recommended as it can interrupt the life-saving procedure. Going to get the code cart (Choice B) may be necessary in certain situations but should not take precedence over providing immediate assistance in CPR. Validating the client's advanced directive (Choice D) is not the primary role in this scenario where urgent action is needed to support the client's circulation and breathing.
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