a client is receiving treatment for hypertension which of these findings would be most concerning to the nurse
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Nursing Elites

HESI RN

Nutrition HESI Practice Exam

1. A client is receiving treatment for hypertension. Which of these findings would be most concerning to the nurse?

Correct answer: C

Rationale: The correct answer is C. A respiratory rate of 16 breaths per minute is within normal limits; however, changes in breathing patterns can indicate respiratory distress, which is concerning, especially in a client receiving treatment for hypertension. A heart rate of 90 beats per minute may not be alarming if the client is at rest. A blood pressure of 120/80 mm Hg is within the normal range for a healthy adult. A temperature of 98.6 degrees Fahrenheit is also considered normal, showing no immediate cause for concern in this scenario.

2. During the care of a client with a salmonella infection, what is the primary nursing intervention to limit transmission?

Correct answer: A

Rationale: The correct answer is to wash hands thoroughly before and after client contact when caring for a client with a salmonella infection. This approach is crucial in preventing the transmission of the infection. While wearing gloves when in contact with body secretions (Choice B), double gloving when in contact with feces or vomitus (Choice C), and wearing gloves when disposing of contaminated linens (Choice D) are important infection control measures, the primary intervention to limit the spread of salmonella is proper hand hygiene.

3. The nurse is caring for a client with liver cirrhosis. Which of these findings would indicate that the client is experiencing complications of the disease?

Correct answer: D

Rationale: Clay-colored stools and dark urine are classic signs of liver dysfunction, indicating bile flow obstruction commonly seen in liver cirrhosis. This finding is a significant complication requiring immediate medical evaluation. Yellowing of the skin and eyes (jaundice) is a common symptom of liver dysfunction but is not specific to complications. Spider angiomas and ascites with peripheral edema are also associated with liver cirrhosis, but they are not indicative of immediate complications as clay-colored stools and dark urine are.

4. The nurse is about to assess a 6-month-old child with nonorganic failure-to-thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be

Correct answer: D

Rationale: A baby with nonorganic failure-to-thrive often appears pale, thin, and uninterested in their surroundings. Choice A is incorrect as 'irritable and colicky with no attempts to pull to standing' is more indicative of other conditions like colic. Choice B is incorrect as a baby with nonorganic failure-to-thrive is unlikely to be alert, laughing, and playing, as they would typically present with signs of failure to thrive. Choice C is incorrect as dusky skin color and poor skin turgor are not typical findings in a baby with nonorganic failure-to-thrive.

5. A nurse is reinforcing teaching with a client who has COPD. Which of the following instructions by the nurse is appropriate?

Correct answer: D

Rationale: The correct answer is to instruct the client to increase protein intake. This is appropriate because increasing protein intake can help maintain muscle mass and strength in clients with COPD. Option A, 'Drink carbonated beverages,' is incorrect as carbonated beverages can exacerbate COPD symptoms. Option B, 'Decrease fiber intake,' is also incorrect as fiber is important for digestion and should not be decreased unless specifically advised by a healthcare provider. Option C, 'Use bronchodilators after meals,' is incorrect because bronchodilators are typically used before meals to help open the airways for better breathing, not after meals.

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