HESI RN
HESI Nutrition Proctored Exam Quizlet
1. For a client with chronic kidney disease having a hemoglobin level of 8.0 g/dL, which intervention should the nurse perform first?
- A. Administer erythropoietin as ordered
- B. Monitor the client's blood pressure
- C. Monitor the client's oxygen saturation level
- D. Assess the client for signs of fatigue
Correct answer: A
Rationale: Administering erythropoietin is the priority intervention for a client with chronic kidney disease and a low hemoglobin level. Erythropoietin stimulates red blood cell production, helping to manage anemia in these clients. Monitoring blood pressure, oxygen saturation level, and assessing for signs of fatigue are important aspects of care but addressing the anemia by administering erythropoietin takes precedence to improve oxygen-carrying capacity and overall well-being.
2. A client is lactose intolerant, and a nurse is reinforcing teaching. Which of the following statements should the nurse include?
- A. You should increase the fiber in your diet.
- B. You should increase the calories in your diet.
- C. You should decrease the dairy products in your diet.
- D. You should decrease the amount of vitamin D in your diet.
Correct answer: C
Rationale: The correct statement for a client who is lactose intolerant is to decrease dairy products since lactose intolerant individuals should avoid dairy to prevent symptoms like bloating, diarrhea, and gas. Increasing fiber (Choice A) or calories (Choice B) is not directly related to lactose intolerance. Decreasing vitamin D (Choice D) is not necessary as lactose intolerance is about the sugar in dairy, not vitamin D.
3. 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?
- A. Add a thickening agent to the fluids
- B. Check the client's gag reflex
- C. Feed the client only solid foods
- D. Increase the rate of intravenous fluids
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.
4. A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to
- A. have the client identify coping methods
- B. get the description of the location and intensity of the pain
- C. accept the client's report of pain
- D. determine the client's status of pain
Correct answer: B
Rationale: The correct answer is B: 'get the description of the location and intensity of the pain.' When a client complains of pain, the initial step in pain assessment is to gather information about the location and intensity of the pain. This helps the nurse understand the nature of the pain and lays the groundwork for further assessment and management. Choice A is incorrect because identifying coping methods comes later in the assessment process. Choice C is incorrect as accepting the client's report of pain is important, but not the first step. Choice D is incorrect as determining the client's pain status also comes after gathering information about the pain.
5. A nurse is contributing to the plan of care of a client who has had a stroke. The client is experiencing severe dysphagia with choking and coughing while eating. Which of the following nutritional therapies should the nurse expect to include in the plan of care?
- A. NPO until dysphagia subsides
- B. Supplements via NG tube
- C. Initiation of total parenteral nutrition
- D. Mechanical soft diet
Correct answer: D
Rationale: The correct answer is D: Mechanical soft diet. A mechanical soft diet is appropriate for clients with severe dysphagia as it helps reduce the risk of choking and aspiration by providing food that is easier to swallow. Choice A, NPO until dysphagia subsides, may be necessary initially but is not a long-term solution. Choice B, supplements via NG tube, may be considered if the client is unable to meet their nutritional needs orally, but it does not address the texture modification needed for dysphagia. Choice C, initiation of total parenteral nutrition, is typically reserved for clients who cannot tolerate any oral intake and is not the first-line option for dysphagia management.
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