HESI RN
HESI Nutrition Proctored Exam Quizlet
1. 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.
2. A client admitted from a nursing home after several recent falls needs a urine sample for culture and sensitivity. What should the nurse complete first?
- A. Obtain urine sample for culture and sensitivity.
- B. Administer intravenous antibiotics.
- C. Encourage protein intake and additional fluids.
- D. Consult physical therapy for gait training.
Correct answer: A
Rationale: In this scenario, the priority intervention is to obtain a urine sample for culture and sensitivity. Older adults with recent falls may have atypical symptoms of urinary tract infection (UTI), which can present as new-onset confusion or falling. It is crucial to rule out UTI before initiating antibiotics. While administering antibiotics, encouraging protein intake, fluids, and consulting physical therapy are important interventions, they should follow the urine sample collection to ensure accurate diagnosis and appropriate treatment.
3. The nurse is caring for a client with a suspected myocardial infarction (MI). Which laboratory test result is most indicative of a recent MI?
- A. Elevated troponin levels
- B. Increased white blood cell count
- C. Increased lactate dehydrogenase (LDH)
- D. Elevated C-reactive protein (CRP)
Correct answer: A
Rationale: Elevated troponin levels are the most specific and sensitive indicator of myocardial infarction. Troponin levels increase within hours of an MI and remain elevated for several days. White blood cell count, lactate dehydrogenase (LDH), and C-reactive protein (CRP) are not specific markers for MI. An increased white blood cell count may indicate inflammation or infection, increased LDH levels can be seen in various conditions like liver disease or muscle injury, and elevated CRP is a general marker of inflammation rather than specific to MI.
4. Which nursing intervention is most important to assist in detecting hypopituitarism and hyperpituitarism in children?
- A. Carefully recording the height and weight of children to detect inappropriate growth.
- B. Performing head circumference measurements on infants under one year of age.
- C. Assessing for behavioral problems at home and school by interviewing the parents.
- D. Noting tracked weight gain without a gain in height on a growth chart.
Correct answer: A
Rationale: Recording the height and weight of children is crucial in detecting growth abnormalities like hypopituitarism and hyperpituitarism. Inappropriate growth patterns, such as disproportionate weight gain or stunted height, can be indicative of these conditions. Regular monitoring of height and weight is a fundamental nursing intervention that can aid in the early identification and management of pituitary-related disorders in children.
5. A client who had a gestational trophoblastic disease (GTD) evacuated 2 days ago is being monitored for choriocarcinoma. She lives in a rural area, and her husband takes the family car to work daily, leaving her without transportation during the day. What intervention is most important for the nurse to implement?
- A. Teach the client about the use of a home pregnancy test.
- B. Schedule a weekly home visit to draw hCG values.
- C. Make a 5-week follow-up appointment with the healthcare provider.
- D. Begin chemotherapy administration during the first home visit.
Correct answer: B
Rationale: Scheduling weekly home visits to monitor hCG levels is critical for early detection of choriocarcinoma, a potential complication of GTD. Choice A is incorrect because a home pregnancy test is not the appropriate method to monitor for choriocarcinoma. Choice C is less frequent than necessary for close monitoring. Choice D is incorrect as chemotherapy administration should be based on confirmed diagnosis and treatment plan, not initiated during the first home visit.