a client with a history of asthma is admitted to the emergency department with difficulty breathing which of these assessments is the highest priority
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Nursing Elites

HESI RN

HESI Nutrition Exam

1. A client with a history of asthma is admitted to the emergency department with difficulty breathing. Which of these assessments is the highest priority for the nurse to perform?

Correct answer: A

Rationale: Auscultation of breath sounds is the highest priority assessment in a client with a history of asthma experiencing difficulty breathing. It helps the nurse evaluate the severity of the asthma exacerbation by listening for wheezing, crackles, or decreased breath sounds. This assessment guides treatment decisions, such as administering bronchodilators or oxygen therapy. Measurement of peak expiratory flow, although important in assessing asthma severity, may not be feasible in an emergency situation where immediate intervention is needed. Observation of accessory muscle use and assessment of skin color are also important assessments in asthma exacerbation, but auscultation of breath sounds takes precedence in determining the need for urgent interventions.

2. An 86-year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next?

Correct answer: B

Rationale: Checking the client's gag reflex is crucial in this situation as coughing while consuming liquids can indicate a risk of aspiration. Assessing the gag reflex can help determine if the client is safe to swallow without inhaling fluids into the lungs, which could lead to further respiratory complications. Adding a thickening agent may not address the underlying issue of aspiration risk. Feeding the client only solid foods is not appropriate without assessing the swallowing safety first. Increasing the rate of intravenous fluids does not directly address the client's difficulty with liquid intake.

3. The nurse is teaching an 87-year-old client methods for maintaining regular bowel movements. The nurse would caution the client to AVOID

Correct answer: C

Rationale: The correct answer is C: Laxatives. Laxatives can be harsh on elderly clients, leading to dependence and potential side effects. While fiber supplements (B) and stool softeners (D) are generally safe options to promote regular bowel movements, laxatives should be used cautiously in older adults due to their potential risks. Glycerin suppositories (A) can also be a safe and effective option for managing constipation in the elderly, but laxatives should be avoided unless deemed necessary by a healthcare provider.

4. A nurse is assisting with the development of an education program for a community group about intake of vitamins and minerals in the diet. Which of the following foods should the nurse recommend as the best source of vitamin C?

Correct answer: B

Rationale: The correct answer is B: 1 medium orange. Oranges are well-known for being rich in vitamin C, an essential nutrient for immune function and skin health. While choices A, C, and D also contain some vitamin C, the medium orange provides a higher amount of this vitamin compared to a ½ cup of green pepper, ½ cup of cabbage, or a medium tomato.

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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