HESI RN
HESI Nutrition Practice Exam
1. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client?
- A. The tube will drain fluid from your chest.
- B. The tube will remove excess air from your chest.
- C. The tube controls the amount of air that enters your chest.
- D. The tube will seal the hole in your lung.
Correct answer: B
Rationale: The correct answer is B: 'The tube will remove excess air from your chest.' In a spontaneous pneumothorax, air accumulates in the pleural space, causing lung collapse. The chest tube is inserted to remove this excess air, allowing the lung to re-expand. Choices A, C, and D are incorrect because the primary purpose of a chest tube in pneumothorax is to evacuate air, not fluid, control air entry, or seal a lung hole.
2. The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best?
- A. Only refer to the client by gender.
- B. Identify the client only by age.
- C. Avoid using the client's name.
- D. Discuss the client another time.
Correct answer: D
Rationale: The best nursing action is to discuss the client another time. When discussing a client's confidential information, it is essential to ensure privacy and confidentiality. Given the presence of other clients in the immediate vicinity, it is inappropriate to discuss personal details about a client's condition openly. Waiting for a more private setting is crucial to uphold the client's right to privacy and confidentiality. Choices A, B, and C are not appropriate because referring to the client only by gender, age, or avoiding the client's name does not address the issue of discussing confidential information in a public setting, which compromises the client's privacy and confidentiality.
3. Which actions are likely to help promote the self-esteem of a male client with major depression?
- A. Ask the client about his long-term goals.
- B. Discuss the challenges of his medical condition.
- C. Include the client in determining treatment protocol.
- D. Encourage the client to engage in recreational therapy.
Correct answer: C
Rationale: Including the client in determining the treatment protocol is the most suitable action to promote the self-esteem of a male client with major depression. This approach empowers the client, involves him in decision-making regarding his care, and fosters a sense of control and self-worth. Option A, asking about his long-term goals, may not directly address his immediate self-esteem needs related to his current condition. Option B, discussing the challenges of his medical condition, may inadvertently focus on negative aspects and potentially lower self-esteem. Option D, encouraging engagement in recreational therapy, is beneficial but may not directly address the client's sense of control and self-worth in decision-making related to his treatment.
4. At 40 weeks gestation, a client presents to the obstetrical floor with spontaneous rupture of amniotic membranes at home and is in active labor. The client feels the need to bear down and push. What information is most important for the nurse to obtain first?
- A. Estimated amount of fluid.
- B. Any odor noted when membranes ruptured.
- C. Color and consistency of fluid.
- D. Time the membranes ruptured.
Correct answer: C
Rationale: The color and consistency of the amniotic fluid are crucial to assess as they can provide valuable information about the presence of meconium, which may indicate fetal distress. Meconium-stained amniotic fluid can lead to complications such as meconium aspiration syndrome in the newborn. Therefore, assessing the color and consistency of the amniotic fluid is the priority in this situation to ensure timely interventions if needed. Estimated amount of fluid (Choice A) may be important but not as critical as assessing for meconium. Any odor noted when membranes ruptured (Choice B) is less relevant compared to assessing for meconium. Knowing the time the membranes ruptured (Choice D) is important but does not take precedence over assessing for fetal distress indicated by meconium presence.
5. The nurse is preparing a discharge teaching plan for a liver transplant client. Which instruction is most important to include in this plan?
- A. Ensure daily follow-up with the healthcare provider
- B. Take immunosuppressant medications as prescribed
- C. Avoid crowds for the first two months after surgery
- D. Return to work in three months
Correct answer: B
Rationale: The most critical instruction to include in the discharge teaching plan for a liver transplant client is to take immunosuppressant medications as prescribed. This is vital to prevent organ rejection and ensure the success of the transplant. While ensuring daily follow-up with the healthcare provider is important for monitoring progress, avoiding crowds for the first two months after surgery helps reduce the risk of infections but is not as crucial as medication adherence. Returning to work in three months is a consideration but not the most important aspect immediately post-transplant.