HESI RN
Nutrition HESI Practice Exam
1. What is the most effective nursing intervention to prevent atelectasis from developing in a postoperative client?
- A. Maintain adequate hydration
- B. Assist the client to turn, deep breathe, and cough
- C. Ambulate the client within 12 hours
- D. Splint the incision
Correct answer: B
Rationale: The correct answer is to assist the client to turn, deep breathe, and cough. This intervention helps to expand the lungs and prevent atelectasis in postoperative clients. Maintaining adequate hydration is important for overall health but is not the most effective intervention for preventing atelectasis. Ambulating the client within 12 hours is beneficial for preventing complications after surgery, but it may not be as directly effective in preventing atelectasis as turning, deep breathing, and coughing. Splinting the incision is important for postoperative care, but it does not specifically address the prevention of atelectasis.
2. A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic?
- A. Bruising at the operative site
- B. Elevated heart rate
- C. Decreased platelet count
- D. No bowel movement for 3 days
Correct answer: D
Rationale: The correct answer is D. Constipation is a common side effect of Tylenol #3, which contains codeine. Codeine can slow down bowel movements, leading to constipation. Monitoring for constipation and implementing management strategies is crucial. Choices A, B, and C are incorrect because bruising at the operative site, elevated heart rate, and decreased platelet count are not commonly associated side effects of Tylenol #3.
3. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately?
- A. Blood urea nitrogen 50 mg/dl
- B. Hemoglobin of 10.3 g/dl
- C. Venous blood pH 7.30
- D. Serum potassium 6 mEq/L
Correct answer: D
Rationale: A serum potassium level of 6 mEq/L indicates hyperkalemia, which can be life-threatening and requires immediate intervention. Hyperkalemia can lead to dangerous cardiac arrhythmias and must be addressed promptly. The other options are not as urgent. A blood urea nitrogen level of 50 mg/dl may indicate kidney dysfunction but does not require immediate intervention. Hemoglobin of 10.3 g/dl may suggest anemia, which needs management but is not an immediate threat. A venous blood pH of 7.30 may indicate acidosis, which is concerning but not as acutely dangerous as hyperkalemia.
4. A nurse is reinforcing teaching about food choice with the mother of an 8-month-old infant. Which of the following statements by the mother indicates a need for further teaching?
- A. I will give my child peanut butter and mashed egg whites.
- B. I will give my child rice cereal and crackers.
- C. I will give my child pureed liver and strained pears.
- D. I will give my child applesauce and green peas.
Correct answer: A
Rationale: The correct answer is A because peanut butter and egg whites are not recommended for infants under 12 months due to the risk of choking and allergies. Choices B, C, and D are appropriate food choices for an 8-month-old infant. Rice cereal, crackers, pureed liver, strained pears, applesauce, and green peas are all suitable options for introducing solid foods to infants.
5. A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the nurse's initial evening rounds, the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication?
- A. I have a sharp pain in my chest when I take a breath.
- B. I have been coughing up foul-tasting, brown, thick sputum.
- C. I have been sweating all day.
- D. I feel hot off and on.
Correct answer: B
Rationale: Coughing up foul-tasting, brown, thick sputum suggests a possible abscess or secondary infection, requiring attention. Choice A may indicate pleurisy, but the focus should be on the sputum. Choice C may be non-specific and could be related to the infection or fever. Choice D is non-specific and may be expected during an infection.
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