HESI RN
HESI Maternity Test Bank
1. A client is admitted to the postpartum unit and tells the nurse she had rheumatic fever as a child, which resulted in some 'heart damage'. The nurse knows that this client is at particular risk for developing heart failure during the immediate postpartum period. Based on the client's history, which nursing problem has the highest priority?
- A. Nausea and vomiting.
- B. Risk for infection.
- C. Sleep deprivation.
- D. Fluid volume excess.
Correct answer: D
Rationale: Fluid volume excess is a priority concern in this client, as heart damage from rheumatic fever can impair the heart's ability to manage increased blood volume postpartum, leading to potential heart failure. Monitoring and managing fluid volume status are crucial to prevent complications in this high-risk client. Choices A, B, and C are not the highest priority in this situation. Nausea and vomiting, risk for infection, and sleep deprivation are important but do not pose an immediate threat to the client's physiologic stability compared to the risk of heart failure due to fluid volume excess.
2. A child with Leukemia is admitted for chemotherapy, and the nursing diagnosis, altered nutrition, less than body requirements related to anorexia, nausea, vomiting is identified. Which intervention should the nurse include in this child's plan of care?
- A. Allow the child to eat foods desired and tolerated
- B. Restrict foods brought from fast food restaurants
- C. Recommend eating the same foods as siblings eat at home
- D. Encourage a variety of large portions of food at every meal
Correct answer: A
Rationale: The correct intervention for a child with Leukemia undergoing chemotherapy and experiencing altered nutrition, less than body requirements due to anorexia, nausea, and vomiting is to allow the child to eat foods desired and tolerated. This intervention helps improve the child's nutrition intake during chemotherapy. Choice B is incorrect because restricting foods may further limit the child's nutritional intake. Choice C is incorrect because recommending eating the same foods as siblings may not align with the child's preferences or needs during treatment. Choice D is incorrect as encouraging large portions of food at every meal may overwhelm the child and be counterproductive to their nutritional needs.
3. The client with newly diagnosed diabetes mellitus is being taught about managing blood glucose levels. Which statement indicates a need for further teaching?
- A. I will rotate my insulin injection sites to avoid tissue damage.
- B. I will monitor my blood glucose levels before each meal.
- C. I can eat unlimited fruit as it is healthy.
- D. I should carry a fast-acting carbohydrate with me at all times.
Correct answer: C
Rationale: Choice C indicates a need for further teaching because stating 'I can eat unlimited fruit as it is healthy' is incorrect. While fruits are healthy, they also contain natural sugars that can affect blood glucose levels. Portion control is crucial to managing blood glucose levels effectively. Choices A, B, and D demonstrate correct understanding. Rotating insulin injection sites helps prevent tissue damage, monitoring blood glucose levels before meals aids in managing diabetes effectively, and carrying a fast-acting carbohydrate is essential to treat hypoglycemia promptly.
4. Which one of the following statements is NOT true about menstruation?
- A. The average amount of menstrual flow is 50 to 90 ml.
- B. The menstrual flow constitutes serous fluid, necrotic slough.
- C. The cycle is influenced by the ovarian hormones Estrogen and progesterone.
- D. The menstrual flow has non-clotting blood.
Correct answer: D
Rationale: The correct answer is D. The statement that menstrual flow has non-clotting blood is incorrect because menstrual blood can indeed clot. Choices A, B, and C are all true statements about menstruation. Choice A reflects the average amount of menstrual flow, choice B describes the components of menstrual flow, and choice C correctly identifies the ovarian hormones that influence the menstrual cycle.
5. A client is receiving intravenous heparin for a deep vein thrombosis. The healthcare provider should monitor the client for which of the following potential complications?
- A. Hypertension
- B. Tachycardia
- C. Bleeding
- D. Hyperkalemia
Correct answer: C
Rationale: Heparin is an anticoagulant, so the primary potential complication is bleeding. The healthcare provider should monitor the client for signs of bleeding, such as bruising, hematuria, and gastrointestinal bleeding. Hypertension, tachycardia, and hyperkalemia are not direct complications of heparin therapy. Therefore, the correct answer is bleeding, as it is the most significant risk associated with heparin administration.